The utilization of endovascular treatment for ruptured intracranial aneurysms is expected to change since the publication of the International Subarachnoid Aneurysm Trial (ISAT) in 2002. The authors performed this analysis to determine the impact of ISAT results on treatment selection for ruptured intracranial aneurysms and associated in-hospital outcomes using nationally representative data.
We determined the national estimates of treatments used for ruptured intracranial aneurysms and associated in-hospital outcomes, length of stay, mortality, and cost incurred using the Nationwide Inpatient Survey (NIS) data. The NIS is the largest all-payer inpatient care database in the US and contains data from 986 hospitals approximating a 20% stratified sample of US hospitals. All the variables pertaining to hospitalization were compared between 2000–2002 and 2004–2006, and in-hospital outcomes were analyzed using multivariate analysis.
In the 3-year periods prior to and after the ISAT, there were 70,637 and 77,352 admissions for ruptured intracranial aneurysms, respectively. There was a significant increase in endovascular treatment after publication of the ISAT (trend test, p < 0.0001) The in-hospital mortality for ruptured intracranial aneurysm admissions decreased from 27% to 24% (odds ratio [OR] 0.89, 95% CI 0.83–0.96, p = 0.003) after the publication of the ISAT. The cost of hospitalization after adjusting for procedures practices was not significantly higher after the publication of the ISAT ($21,437 vs $22,817, p < 0.89), but cost of hospitalization was higher in the post-ISAT period for patients undergoing endovascular procedure.
The results of the ISAT have been associated with a prominent change in practice patterns related to the treatment of ruptured aneurysms. The cost of hospitalization has increased and the mortality has decreased, presumably due to a larger proportion of patients receiving any treatment and endovascular treatment.
Please include this information when citing this paper: published online July 23, 2010; DOI: 10.3171/2010.6.JNS091486.
AndaluzN,&ZuccarelloM:Recent trends in the treatment of cerebral aneurysms: analysis of a nationwide inpatient database.J Neurosurg108:1163–1169,2008
AusmanJI:ISAT study: is coiling better than clipping?.Surg Neurol59:162–175,2003
BritzGW:ISAT trial: coiling or clipping for intracranial aneurysms?.Lancet366:783–785,2005
BroderickJ,,BrottT,,KothariR,,MillerR,,KhouryJ,&PancioliA,et al.:The Greater Cincinnati/Northern Kentucky Stroke Study: preliminary first-ever and total incidence rates of stroke among blacks.Stroke29:415–421,1998
BroderickJP,,BrottTG,,DuldnerJE,,TomsickT,&LeachA:Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage.Stroke25:1342–1347,1994
CowanJAJr,,DimickJB,,WainessRM,,UpchurchGRJr,&ThompsonBG:Outcomes after cerebral aneurysm clip occlusion in the United States: the need for evidence-based hospital referral.J Neurosurg99:947–952,2003
CrossDTIII,,TirschwellDL,,ClarkMA,,TudenD,,DerdeynCP,&MoranCJ,et al.:Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states.J Neurosurg99:810–817,2003
DerdeynCP,,BarrJD,,BerensteinA,,ConnorsJJ,,DionJE,&DuckwilerGR,et al.:The International Subarachnoid Aneurysm Trial (ISAT): a position statement from the Executive Committee of the American Society of Interventional and Therapeutic Neuroradiology and the American Society of Neuroradiology.AJNR Am J Neuroradiol24:1404–1408,2003
FraserJF,,RiinaH,,MitraN,,GobinYP,,SimonAS,&StiegPE:Treatment of ruptured intracranial aneurysms: looking to the past to register the future.开云体育app官方网站下载入口59:1157–1167,2006
GnanalinghamKK,,ApostolopoulosV,,BaraziS,&O'NeillK:The impact of the international subarachnoid aneurysm trial (ISAT) on the management of aneurysmal subarachnoid haemorrhage in a neurosurgical unit in the UK.Clin Neurol Neurosurg108:117–123,2006
HarbaughRE,,HerosRC,&HadleyMN:More on ISAT.Lancet361:783–784,2003
HigashidaRT,,LahueBJ,,TorbeyMT,,HopkinsLN,,LeipE,&HanleyDF:Treatment of unruptured intracranial aneurysms: a nationwide assessment of effectiveness.AJNR Am J Neuroradiol28:146–151,2007
HohBL,,RabinovJD,,PryorJC,,CarterBS,&BarkerFGII:In-hospital morbidity and mortality after endovascular treatment of unruptured intracranial aneurysms in the United States, 1996–2000: effect of hospital and physician volume.AJNR Am J Neuroradiol24:1409–1420,2003
IkawaF,,OhbayashiN,,ImadaY,,MatsushigeT,,KajiharaY,&InagawaT,et al.:Analysis of subarachnoid hemorrhage according to the Japanese Standard Stroke Registry Study—incidence, outcome, and comparison with the International Subarachnoid Aneurysm Trial.Neurol Med Chir (Tokyo)44:275–276,2004
InagawaT:Trends in surgical and management outcomes in patients with aneurysmal subarachnoid hemorrhage in Izumo city, Japan, between 1980–1989 and 1990–1998.Cerebrovasc Dis19:39–48,2005
JavadpourM:ISAT: Will the results stand the test of time?.Br J Neurosurg21:7–8,2007
JohnstonSC,,DudleyRA,,GressDR,&OnoL:Surgical and endovascular treatment of unruptured cerebral aneurysms at university hospitals.Neurology52:1799–1805,1999
LanzinoG,,FraserK,,KanaanY,&WagenbachA:Treatment of ruptured intracranial aneurysms since the International Subarachnoid Aneurysm Trial: practice utilizing clip ligation and coil embolization as individual or complementary therapies.J Neurosurg104:344–349,2006
LinfanteI,&WakhlooAK:Brain aneurysms and arteriovenous malformations: advancements and emerging treatments in endovascular embolization.Stroke38:1411–1417,2007
MaudA,,LakshminarayanK,,SuriMF,,VazquezG,,LanzinoG,&QureshiAI:Cost-effectiveness analysis of endovascular versus neurosurgical treatment for ruptured intracranial aneurysms in the United States.J Neurosurg110:880–886,2009
McPheeJT,,SchanzerA,,MessinaLM,&EslamiMH:Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005.J Vasc Surg48:1442–1450,2008
MolyneuxA,,KerrR,,StrattonI,,SandercockP,,ClarkeM,&ShrimptonJ,et al.:International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial.Lancet360:1267–1274,2002
National Institutes for Clinical Excellence:Coil embolization of ruptured intracranial aneurysmsNational Health Service,London UK,(http://www.nice.org.uk:80/nicemedia/live/11036/30674/30674.pdf) [Accessed June 22, 2010]
PobereskinLH:Incidence and outcome of subarachnoid haemorrhage: a retrospective population based study.J Neurol Neurosurg Psychiatry70:340–343,2001
QureshiAI:Endovascular treatment of cerebrovascular diseases and intracranial neoplasms.Lancet363:804–813,2004
QureshiAI,,HutsonAD,,HarbaughRE,,StiegPE,&HopkinsLN:North American Trial of Unruptured and Ruptured Aneurysms Planning Committee:Methods and design considerations for randomized clinical trials evaluating surgical or endovascular treatments for cerebrovascular diseases.开云体育app官方网站下载入口54:248–267,2004
QureshiAI,,JanardhanV,,HanelRA,&LanzinoG:Comparison of endovascular and surgical treatments for intracranial aneurysms: an evidence-based review.Lancet Neurol6:816–825,2007
QureshiAI,,SuriMF,,NasarA,,KirmaniJF,,DivaniAA,&HeW,et al.:Trends in hospitalization and mortality for subarachnoid hemorrhage and unruptured aneurysms in the United States.开云体育app官方网站下载入口57:1–8,2005
QureshiAI,,SuriMF,,NasarA,,KirmaniJF,,EzzeddineMA,&DivaniAA,et al.:Changes in cost and outcome among US patients with stroke hospitalized in 1990 to 1991 and those hospitalized in 2000 to 2001.Stroke38:2180–2184,2007
RaabeA,,SchmiedekP,,SeifertV,&StolkeD:German Society of Neurosurgery Section on Vascular Neurosurgery: Position Statement on the International Subarachnoid Hemorrhage Trial (ISAT).Zentralbl Neurochir64:99–103,2003
Ronne-EngströmE,,EnbladP,,GálG,,NorbäckO,,RyttleforsM,&CesariniKG,et al.:Patients with spontaneous subarachnoid haemorrhage - presentation of a 10-year hospital series.Br J Neurosurg23:499–506,2009
RosamondWD,,FolsomAR,,ChamblessLE,,WangCH,,McGovernPG,&HowardG,et al.:Stroke incidence and survival among middle-aged adults: 9-year follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort.Stroke30:736–743,1999
SaccoS,,TotaroR,,ToniD,,MariniC,,CeroneD,&CaroleiA:Incidence, case-fatalities and 10-year survival of subarachnoid hemorrhage in a population-based registry.Eur Neurol62:155–160,2009
TimaranCH,,VeithFJ,,RoseroEB,,ModrallJG,,ValentineRJ,&ClagettGP:Intracranial hemorrhage after carotid endarterectomy and carotid stenting in the United States in 2005.J Vasc Surg49:623–629,2009
van den BergR,,RinkelGJ,&VandertopWP:Treatment of ruptured intracranial aneurysms: implications of the ISAT on clipping versus coiling.Eur J Radiol46:172–177,2003
WilliamsGR,,JiangJG,,MatcharDB,&SamsaGP:Incidence and occurrence of total (first-ever and recurrent) stroke.Stroke30:2523–2528,1999
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