Highlights
- •Unruptured intracranial aneurysms are increasingly treated endovascularly, becoming the most common modality since 2004.
- •In the past 15 years, Open surgical clipping has decreased over time for unruptured aneurysms.
- •Patients who were treated for unruptured aneurysms had a higher number of pre-existing comorbidities.
- •Racial and socioeconomic disparities present in UIA management, with more private insurer patients undergoing craniotomy compared to endovascular cases.
Abstract
Objective
The approach to intervention for unruptured intracranial aneurysms (UIAs) remains
controversial. Utilization of endovascular techniques for aneurysm repair increased
dramatically during the last decade. We sought to analyze recent national trends for
electively treated (open and endovascular) UIAs focusing on pre-existing patient disease
burden and intervention modality selection.
Methods
The Nationwide Inpatient Sample (NIS) national database was used to identify patients
with primary diagnosis codes of unruptured intracranial aneurysm between 1999 and
2014. Patients were dichotomized by intervention into endovascular or open surgical
treatment. Analysis of pre-existing disease severity were calculated using the Elixhauser
comorbidity index. Complications of combined peri-procedural stroke or death during
admission and hospital length of stay were used as primary endpoints for comparison.
Results
The percent of total UIAs treated electively with open approach decreased from more
than 95 % of cases in 1999 to less than 25 % in 2014. Patients undergoing clipping
were 3 years younger than those in the endovascular group (p < 0.001). The rate of
primary endpoint complications (stroke and death) and length of stay for open cases
saw a decrease throughout the study but remained statistically higher when compared
to the endovascular group over the study period (p < 0.001). Additionally, non-neurologic
complications increased over the time period for open cases. The average preoperative
co-morbid disease severity for all groups treated increased over this interval. Conversely,
the relative volume of endovascular cases increased but the rate of complications
and average group disease remained statistically lower than the surgical clipping
group (p < 0.05).
Conclusion
The percent of UIAs treated electively with open approach has decreased since 1999
with a concomitant increase in complication rate in particular compared to endovascular
cases. However, the health characteristics of patients treated with surgical clipping
show an increase in severity of pre-existing co-morbidities. Further research into
factors contributing to this finding, including potential socioeconomic differences
and changes in surgeon experience are needed.
Keywords
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Article info
Publication history
Published online: November 25, 2022
Accepted:
October 10,
2022
Received:
May 1,
2022
Footnotes
☆Portions of this work was presented as an Oral abstract at the American Association of Neurological Surgeons (AANS) annual meeting in San Diego, CA in 2019.
Identification
Copyright
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