Incidentally discovered unruptured cerebral aneurysms Current status of the Unruptured Cerebral Aneurysm Study in Japan

BackgroundIt is often questioned if one physician can conduct both open and endovascular techniques successfully and safely.ObjectiveTo investigate the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm clipping.MethodsWe performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent surgical clipping for unruptured cerebral aneurysms between 2007 and 2012. To control for confounding we used propensity score conditioning, and controlled for clustering at the physician level.ResultsDuring the study, 3247 patients underwent clipping for unruptured cerebral aneurysms, and met the inclusion criteria. Of these, 766 (23.6%) underwent treatment by hybrid neurosurgeons, and 2481 (76.4%) by proceduralists, who performed only clipping. Multivariable regression analysis with propensity score adjustment demonstrated a lack of association of combined practice with 1-year postoperative mortality (OR=0.81; 95% CI 0.51 to 1.28), discharge to rehabilitation (OR=0.95; 95% CI 0.72 to 1.25), length of stay (adjusted difference 0.85 days; 95% CI −0.31 to 2.00), or 30-day readmission rate (OR=1.05; 95% CI 0.80 to 1.39). Higher procedural volume was independently associated with improved outcomes.ConclusionsIn a cohort of Medicare patients with unruptured aneurysms, we did not demonstrate a difference in mortality, discharge to rehabilitation, or readmission rate between hybrid neurosurgeons and surgeons performing only clipping.

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Size is the Most Important Predictor of Aneurysm Rupture Among Multiple Cerebral Aneurysms: Post Hoc Subgroup Analysis of Unruptured Cerebral Aneurysm Study Japan

Neurosurgery ◽

10.1093/neuros/nyx307 ◽

2017 ◽

Vol 82 (6) ◽

pp. 864-869 ◽

Cited By ~ 12

Author(s):

Masaaki Shojima ◽

Akio Morita ◽

Hirofumi Nakatomi ◽

Shinjiro Tominari

Keyword(s):

Cerebral Aneurysm ◽

Cerebral Aneurysms ◽

Aneurysm Rupture ◽

Ruptured Aneurysm ◽

Clinical Value ◽

Total Cohort ◽

Unruptured Cerebral Aneurysm ◽

Specific Factors ◽

Unruptured Cerebral Aneurysms ◽

Post Hoc

Abstract BACKGROUND Multiple cerebral aneurysms are encountered in approximately 15% to 35% of patients harboring unruptured cerebral aneurysms. It would be of clinical value to determine which of them is most likely to rupture. OBJECTIVE To characterize features of the ruptured aneurysm relative to other concomitant fellow aneurysms in patients with multiple cerebral aneurysms. METHODS From a total of 5720 patients who were prospectively registered in the Unruptured Cerebral Aneurysm Study in Japan, a subgroup of patients with multiple cerebral aneurysms who developed subarachnoid hemorrhage was extracted for this post hoc analysis. Intrapatient comparisons of each aneurysm were carried out using aneurysm-specific factors such as size, location, and shape to identify predictors of rupture among the fellow aneurysms in a patient with multiple cerebral aneurysms. RESULTS Twenty-five patients with 62 aneurysms were identified from the total cohort of 5720 patients. With the distinctiveness in size, which means the aneurysm was the single largest among the multiple aneurysms, the ruptured aneurysm in each case was discriminated from the other coexisting aneurysms with a sensitivity of 0.76 and specificity of 0.86. CONCLUSION Our results suggest that the largest aneurysm is likely to rupture among coexisting aneurysms in a patient with multiple cerebral aneurysms.

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The impact of hybrid neurosurgeons on the outcomes of endovascular coiling for unruptured cerebral aneurysms

Journal of Neurosurgery ◽

10.3171/2015.11.jns151725 ◽

2017 ◽

Vol 126 (1) ◽

pp. 29-35 ◽

Cited By ~ 6

Author(s):

Kimon Bekelis ◽

Dan Gottlieb ◽

Nicos Labropoulos ◽

Yin Su ◽

Stavropoula Tjoumakaris ◽

...

Keyword(s):

Propensity Score ◽

Cerebral Aneurysm ◽

Readmission Rate ◽

Cerebral Aneurysms ◽

Endovascular Coiling ◽

Unruptured Cerebral Aneurysm ◽

Hospital Referral ◽

Unruptured Cerebral Aneurysms ◽

The Impact ◽

Aneurysm Coiling

OBJECTIVE The impact of combined practices on the outcomes of unruptured cerebral aneurysm coiling remains an issue of debate. The authors investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm coiling. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent endovascular coiling for unruptured cerebral aneurysms between 2007 and 2012. To control for confounding, the authors used propensity score conditioning, with mixed effects to account for clustering at the hospital referral region level. RESULTS During the study period, there were 11,716 patients who underwent endovascular coiling for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 1186 (10.1%) underwent treatment performed by hybrid neurosurgeons, and 10,530 (89.9%) by proceduralists who performed only endovascular coiling. Multivariable regression analysis with propensity score adjustment demonstrated a lack of association of combined practice with 1-year postoperative mortality (OR 0.84; 95% CI 0.58–1.23), discharge to rehabilitation (OR 1.0; 95% CI 0.66–1.51), 30-day readmission rate (OR 1.07; 95% CI 0.83–1.38), and length of stay (adjusted difference, 0.41; 95% CI −0.26 to 1.09). Higher procedural volume was independently associated with improved outcomes. CONCLUSIONS In a cohort of Medicare patients, the authors did not demonstrate a difference in mortality, discharge to rehabilitation, readmission rate, and LOS between hybrid neurosurgeons and proceduralists performing only endovascular coiling.

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Management Outcomes in the Unruputred Cerebral Aneurysm Study II (UCAS II): Interim Report : Quest for Standards and Current Status in Japan(Horizons of Treatment for Unruptured Cerebral Aneurysms)

Japanese Journal of Neurosurgery ◽

10.7887/jcns.20.484 ◽

2011 ◽

Vol 20 (7) ◽

pp. 484-490 ◽

Cited By ~ 9

Author(s):

Akio Morita ◽

Keyword(s):

Cerebral Aneurysm ◽

Cerebral Aneurysms ◽

Current Status ◽

Interim Report ◽

Special Issue ◽

Unruptured 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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Outcomes of Elective Cerebral Aneurysm Treatment Performed by Attending Neurosurgeons after Night Work

Neurosurgery ◽

10.1093/neuros/nyx174 ◽

2017 ◽

Vol 82 (3) ◽

pp. 329-334 ◽

Cited By ~ 3

Author(s):

Kimon Bekelis ◽

Symeon Missios ◽

Todd A MacKenzie

Keyword(s):

Length Of Stay ◽

Cerebral Aneurysm ◽

New York State ◽

Cerebral Aneurysms ◽

Work Hours ◽

Endovascular Coiling ◽

Emergency Procedures ◽

Aneurysm Treatment ◽

Unruptured Cerebral Aneurysm ◽

Unruptured Cerebral Aneurysms

Abstract BACKGROUND The association between long work hours and outcomes among attending surgeons remains an issue of debate. OBJECTIVE To investigate whether operating emergently the night before an elective case was associated with inferior outcomes among attending neurosurgeons. METHODS We executed a cohort study with unruptured cerebral aneurysm patients, who underwent endovascular coiling or surgical clipping from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System database. We investigated the association of treatment by surgeons performing emergency procedures the night before with outcomes of elective cerebral aneurysm treatment using an instrumental variable analysis. RESULTS Overall, 4700 patients underwent treatment for unruptured cerebral aneurysms. There was no difference in inpatient mortality (adjusted difference, –0.7%; 95% confidence interval [CI], –1.4% to 0.02%), discharge to a facility (adjusted difference, –0.1%; 95% CI, –1.2% to 1.2%), or length of stay (adjusted difference, –0.58; 95% CI, –1.66 to 0.50) between patients undergoing elective cerebral aneurysm treatment by surgeons who performed emergency procedures the night before, and those who did not. CONCLUSION Using a comprehensive patient cohort in New York State for elective treatment of unruptured cerebral aneurysms, we did not identify an association of treatment by surgeons performing emergency procedures the night before, with mortality, discharge to a facility, or length of stay. Our study had 80% power to detect differences in mortality (our primary outcome), as small as 4.1%. The results of the present study do not support the argument for regulation of attending work hours.

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Risk of unruptured aneurysm treatment in California

Stroke ◽

10.1161/str.32.suppl_1.381-a ◽

2001 ◽

Vol 32 (suppl_1) ◽

pp. 381-381

Author(s):

S. Claiborne Johnston ◽

Shoujun Zhao ◽

R. Adams Dudley ◽

Daryl R Gress

Keyword(s):

Adverse Events ◽

Cerebral Aneurysm ◽

Endovascular Therapy ◽

Odds Ratio ◽

Cerebral Aneurysms ◽

Hospital Treatment ◽

Hospital Death ◽

Hospital Deaths ◽

The Difference ◽

Unruptured Cerebral Aneurysms

P230 Background. Few studies have directly compared the risk of cerebral aneurysm repair with surgery and with endovascular coil embolization. Since the vast majority of patients with unruptured cerebral aneurysms are non-disabled prior to treatment, this diagnosis provides an opportunity to compare risks of treatment. Methods. Discharge abstracts for all patients with a primary diagnosis of unruptured cerebral aneurysm were retrieved from a statewide database of non-Federal hospital discharges in California from January 1990 through December 1998. Admissions for initial treatment and all follow-up care were combined to reflect the entire course of therapy. An adverse event was defined as an in-hospital death or discharge to nursing home or rehabilitation hospital at any point during the treatment course. Results. A total of 2069 patients were treated for unruptured aneurysms. Adverse outcomes were more frequent in the 1699 patients treated with surgery than in the 370 treated with endovascular therapy (25% vs. 10%; p<0.0001 by chi-square test). The difference persisted after adjustment for age, gender, race, source of admission, and year of treatment (odds ratio 3.5 for adverse events surgery vs. endovascular therapy, 95% confidence interval 2.4–5.2, p<0.0001 by logistic regression). In-hospital deaths occurred in 3.5% of surgical cases and 0.5% of endovascular cases (p=0.003), and the difference remained significant after adjustment in multivariable models (odds ratio 6.3, 1.5–26.2, p=0.01). Adverse events were less likely at hospitals treating a larger portion of patients with endovascular therapy after adjustment for case characteristics, hospital treatment volume, and clustering of observations using generalized estimating equations (p=0.006). Conclusions. In California, endovascular repair of unruptured cerebral aneurysms is associated with fewer adverse events and in-hospital deaths than surgery.

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Efficacy of Intraoperative Blood Salvage in Cerebral Aneurysm Surgery

Journal of Clinical Medicine ◽

10.3390/jcm10245734 ◽

2021 ◽

Vol 10 (24) ◽

pp. 5734

Author(s):

Bedjan Behmanesh ◽

Florian Gessler ◽

Elisabeth Adam ◽

Ulrich Strouhal ◽

Sae-Yeon Won ◽

...

Keyword(s):

Cost Effectiveness ◽

Blood Cell ◽

Cerebral Aneurysm ◽

Red Blood Cell ◽

Cerebral Aneurysms ◽

Cell Salvage ◽

Aneurysm Surgery ◽

Allogenic Blood ◽

Intraoperative Cell Salvage ◽

Unruptured Cerebral Aneurysm

Background. The use and effectiveness of intraoperative cell salvage has been analyzed in many surgical specialties. Until now, no data exist evaluating the efficacy of intraoperative cell salvage in cerebral aneurysm surgery. Aim. To evaluate the efficacy and cost effectiveness of intraoperative cell salvage in cerebral aneurysm surgery. Methods. Data were collected retrospectively for all the patients who underwent cerebral aneurysm surgery at our institution between 2013 and 2019. Routinely, we apply blood salvage through autotransfusion. The cases were divided into a ruptured cerebral aneurysm group and a unruptured cerebral aneurysm group. Results. A total of 241 patients underwent cerebral aneurysm clipping. Of all the cerebral aneurysms, 116 were ruptured and 125 were unruptured and clipped electively. Age, location of the aneurysm, postoperative red blood cell count, intraoperative blood loss, and number of allogenic blood cell transfusions were statistically significantly different between the groups. The autotransfusion of salvaged blood could only be facilitated in eight cases with ruptured cerebral aneurysms and in none with unruptured cerebral aneurysms clipped electively (p < 0.01). Additionally, 35 patients with ruptured cerebral aneurysms and one patient with unruptured cerebral aneurysm required allogenic red blood cell transfusion after surgery, and 71 vs. 2 units of blood were transfused (p < 0.0001). In terms of cost effectiveness, a total of EUR 45,189 in 241 patients was spent to run the autotransfusion system, while EUR 13,797 was spent for allogenic blood transfusion. Conclusions. The use of cell salvage in patients with unruptured cerebral aneurysm, undergoing elective surgery, is not effective.

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Verbal Memory Functions in Patients after the Ruptured and Unruptured Cerebral Aneurysm Surgery

Archives of Psychiatry Research ◽

10.20471/may.2021.57.01.10 ◽

2020 ◽

Vol 57 (1) ◽

pp. 81-92

Author(s):

Ljiljana Pačić-Turk ◽

Valerija Hauptfeld ◽

Lana Maljković ◽

Ivo Somek ◽

Larissa Kalaus

Keyword(s):

Cerebral Aneurysm ◽

Verbal Memory ◽

Verbal Learning ◽

Cerebral Aneurysms ◽

Anterior Communicating Artery ◽

Aneurysm Surgery ◽

Brain Aneurysm ◽

Memory Functions ◽

Unruptured Cerebral Aneurysm ◽

Significant Difference

A cerebral aneurysm is a bulge in the wall of a brain blood vessel with a risk to rupture. It occurs in about 2% of the population, somewhat more often in women. Most aneurysms are located in the anterior circulation area. Aneurysm rupture is relatively rare and accounts for 5% of all cerebrovascular brain incidents. Ruptured and asymptomatic/unruptured aneurysms are often treated surgically at the Department of Neurosurgery, Medical School University of Zagreb. The study included 134 patients after cerebral aneurysm surgery during the last 10 years, and neuropsychological testing was performed on average 77 days after surgery. The average age was 52 years and they completed an average of 12 years of education. In the group of patients included in this study, 40.3% of them were operated after ruptured, and 59.7% for unruptured cerebral aneurysm. Most aneurysms were located in the middle cerebral and anterior communicating arteries. With regard to lateralization, there was an equal number of aneurysms located in the right and left hemisphere and bilaterally (on the anterior communicating artery). As part of regular neuropsychological assessment, tests of verbal learning and memory (numerical, logical and mechanical memory) were applied. The aims of the study were to find out whether patients operated for ruptured cerebral aneurysms show greater verbal memory impairments than patients operated for unruptured cerebral aneurysms and whether there was the significant effect of lateralization of aneurysm (to check the interaction effect of both rupture and lateralization on those functions). The results obtained show that, even though there are no statistically significant differences between groups of patients that underwent surgery for ruptured and unruptured brain aneurysm, patients show a trend of somewhat better results on most of the verbal memory functions after surgery for unruptured brain aneurysm. The results show statistically significant difference between groups of patients that underwent surgery for ACoA aneurysm and those with right lateralized cerebral aneurysms on most of the trails on AVLT test. Also, patients with operated ACoA aneurysm have significantly worse scores in learning process (AVLT 3 and AVLT 4) and especially on short-term and long-term verbal memory than the patients who were operated for left or right lateralized aneurysm.

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Small vs. Large Unruptured Cerebral Aneurysm: Concerns With the Age of Patient

Frontiers in Neurology ◽

10.3389/fneur.2021.735456 ◽

2021 ◽

Vol 12 ◽

Author(s):

Jianfeng Zheng ◽

Ru Xu ◽

Xiaochuan Sun ◽

Xiaodong Zhang

Keyword(s):

Older Patients ◽

Multivariable Analysis ◽

Cerebral Aneurysms ◽

Preventive Treatment ◽

Maximum Diameter ◽

Poor Outcome ◽

Clinical Complications ◽

Unruptured Cerebral Aneurysm ◽

Unruptured Cerebral Aneurysms ◽

The Impact

Objective: The coiling and clipping of unruptured cerebral aneurysms (UCAs) in older patients has increased rapidly, and aneurysm size was a significant factor for decision-making in the treatment of UCAs. The purpose of the study was to investigate the impact of age on the functional outcomes of patients between the small versus large UCAs.Methods: We conducted a retrospective study for consecutive cases of UCAs admitted from May 2011 to December 2020. According to the maximum diameter of UCA, patients were divided into small UCAs (≤ 5 mm) group and large UCAs (>5 mm) group. Baseline characteristics, clinical complications, and outcomes of patients between the two groups were analyzed.Results: A total of 564 UCA patients received preventive treatment, including 165 small UCAs and 399 large UCAs. Compared with the small UCA group, the incidence of ischemia event in the large UCA group was significantly higher (7.3 vs. 2.4%; p = 0.029). Multivariable analysis demonstrating age (p = 0.006) and treatment modality (p < 0.001) were independent risk factors associated with poor outcome for patients with large UCAs.Conclusions: Preventive treatment of small UCAs is safe and effective, but older patients with large UCAs are at high risk of poor outcome, and the operations should be more cautious.

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