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Machado EAT, Batista S, Braga FDO, Alves Filho CAF, Almeida Filho JA, Lopes PG, Cartobei CL, Oliveira LDB, Pereira PJDM, Niemeyer Filho P. Optimizing resources: financial evaluation of flow diverters versus stent assisted coiling in large and giant cerebral aneurysm management in Brazil public health system. J Neurointerv Surg 2024:jnis-2024-021583. [PMID: 38503509 DOI: 10.1136/jnis-2024-021583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/04/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cerebral aneurysms, especially large and giant aneurysms, pose challenges in neurointerventional surgery. Treatment choices involve clinical presentation, aneurysm details, and global resource variations. Neurointerventional methods, while innovative, may be cost restrictive in certain regions. In public healthcare, cost is crucial, notably in countries like Brazil. This study examines the device specific cost estimation of flow diverters (FD) and traditional stent assisted coiling (SAC) for large and giant cerebral aneurysms, providing insights into optimizing neurosurgical interventions within the Brazilian public health system's unique challenges. METHODS A comprehensive retrospective analysis was conducted at our medical center of cases of large and giant aneurysms treated between 2013 and 2023. Determination of the estimated number of coils for aneurysms previously treated with FDs at our center was made, with the cost of each case, and the difference between both treatments was calculated. RESULTS We investigated the profiles of 77 patients: 40 had large aneurysms (51.9%) and 37 had giant aneurysms (48.1%). Large aneurysms had a mean cost difference of US$274 (standard deviation (SD) $2071), underscoring the device specific cost estimation of FDs over SAC in their treatment. For giant aneurysms, the mean cost difference increased to $6396 (SD $2694), indicating FDs as the more economically sound choice. CONCLUSION Our study indicated that, for the treatment of giant aneurysms and some large aneurysms, the FD intervention was more economical than SAC.
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Affiliation(s)
| | - Savio Batista
- Department of Endovascular Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fausto de Oliveira Braga
- Department of Endovascular Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | | | | | - Plínio Gabriel Lopes
- Department of Endovascular Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Carlos Leandro Cartobei
- Department of Endovascular Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | | | | | - Paulo Niemeyer Filho
- Department of Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
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Nasra M, Maingard JT, Hall J, Mitreski G, Kuan Kok H, Smith PD, Russell JH, Jhamb A, Brooks DM, Asadi H. Clipping versus coiling: A critical re-examination of a decades old controversy. Interv Neuroradiol 2024; 30:86-93. [PMID: 36017537 PMCID: PMC10956463 DOI: 10.1177/15910199221122854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Two major studies, The International Subarachnoid Aneurysm Trial and the Barrow Ruptured Aneurysm Trial, compare the long-term outcomes of clipping and coiling. Although these demonstrated coiling's initial benefits, rebleeding and retreatment rates as well as converging patient outcomes sparked controversy regarding its durability. This article will critically examine the available evidence for and against clipping and coiling of intracranial aneurysms. Critics of endovascular treatment state that the initial benefit seen with endovascular coiling decreases over the duration of follow-up and eventually functional outcomes of both treatment modalities are similar. Combined with the increased rate of retreatment and rebleeding, these trials reveal that coiling is not as durable and not as effective as a long-term treatment compared to clipping. Also, due to the cost of devices following endovascular treatment and prolonged hospitalization following clipping, the financial burden has been considered controversial. SUMMARY/KEY MESSAGES Short-term outcomes reveal better morbidity and mortality outcomes following coiling. Despite the higher rates of retreatment and rebleeding with coiling, there was no significant change in functional outcomes following retreatment. Furthermore, examining more recent trials reveals a decreased rate of recurrence and rebleeding with improved technology and expertise. Functional outcomes deteriorate for both cohorts over time while recent results revealed improved long-term cognitive outcomes and levels of health-related quality of life after coiling in comparison to clipping. The expense of longer hospital stays following clipping must be balanced against the expense of endovascular devices in coiling.
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Affiliation(s)
| | - Julian Tam Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
| | - Jonathan Hall
- Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Goran Mitreski
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service, Northern Hospital, Epping, Victoria, Australia
| | - Paul D. Smith
- Department of Neurosurgery, St Vincent's Hospital, Fitzroy, Victoria, Melbourne, Australia
- Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Jeremy H. Russell
- Department of Neurosurgery, Austin Health, Heidelberg, Victoria, Australia
| | - Ashu Jhamb
- Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Duncan Mark Brooks
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
- School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
- School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
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3
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Lauzier DC, Cler SJ, Srienc AI, Patel B, Pierce A, Gagne J, Vellimana AK, Chatterjee AR, Kansagra AP, Moran CJ, Zipfel GJ, Osbun JW. Comparative cost analysis of endovascular and open approaches for elective treatment of middle cerebral artery aneurysms. Interv Neuroradiol 2023:15910199231221298. [PMID: 38105434 DOI: 10.1177/15910199231221298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Intracranial aneurysms of the middle cerebral artery can be treated using several open surgical and endovascular approaches. Given the growing evidence of clinical equipoise between these various treatment strategies, there is a need to assess the costs associated with each. METHODS Cost of aneurysm treatment was divided into two categories for comparison. "Initial cost" comprised the total in-hospital expenses for initial aneurysm treatment and "total cost" comprised initial aneurysm treatment and all expenses relating to readmission due to treatment-related complications, prescribed catheter angiograms for monitoring of treatment stability, and any retreatments needed for a given aneurysm. The open surgical group was subdivided into a pterional approach group and a lateral supraorbital (LSO) approach group for. RESULTS Median initial cost was $37,152 (IQR $31,318-$44,947) for aneurysms treated with the pterional approach, $29,452 (IQR $27,779-$32,826) for aneurysms treated with the LSO approach, and $19,587 (IQR $14,125-$30,521) for aneurysms treated with endovascular approaches. The median total cost was $39,737 (IQR $33,891-$62,259) for aneurysms treated with the pterional approach, $31,785 (IQR $29,513-$41,099) for aneurysms treated with the LSO approach, and $24,578 (IQR $18,977-$34,547) for aneurysms treated with endovascular approaches. Analysis of variance test demonstrated variance across groups for both initial and total cost (p = 0.004, p = 0.008, respectively). In our subsequent analysis, initial cost and total cost were higher in the pterional group than the endovascular group (p = 0.003 and p = 0.006, respectively). CONCLUSIONS Endovascular treatment of elective aneurysms has a significantly lower cost than open surgical treatment with the pterional approach, but not with the LSO approach. For aneurysms not amenable to endovascular treatment, a minimally invasive LSO approach carries a lower cost burden than a pterional approach.
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Affiliation(s)
- David C Lauzier
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Samuel J Cler
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Anja I Srienc
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Bhuvic Patel
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Andrew Pierce
- Barnes Jewish Hospital Clinical Operations, St Louis, MO, USA
| | - Jason Gagne
- Barnes Jewish Hospital Clinical Operations, St Louis, MO, USA
| | - Ananth K Vellimana
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Arindam R Chatterjee
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Akash P Kansagra
- Department of Neurointerventional Surgery, California Center for Neurointerventional Surgery, St Louis, MO, USA
| | - Christopher J Moran
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Joshua W Osbun
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, MO, USA
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Dokponou YCH, Alihonou T, Adjiou DKFDP, Obame FLO, Nyalundja AD, Dossou MW, Murhega RB, Lawson LD, Badirou OBA, Kpègnon NA, Bankole NDA. Surgical Aneurysm Repair of Aneurysmal Subarachnoid Hemorrhage in Sub-Saharan Africa: The State of Training and Management. World Neurosurg 2023; 176:e485-e492. [PMID: 37257644 DOI: 10.1016/j.wneu.2023.05.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND In a resource-limited setting such as sub-Saharan African countries, neurosurgeons need training and fellowship for surgical repair of aneurysmal subarachnoid hemorrhage (aSAH). Surgical repair of ruptured aneurysms costs less and requires less instrumentation compared with endovascular procedures. The purpose of this study is to evaluate the state of training and management of aSAH in sub-Saharan Africa training centers. METHODS An e-survey was sent as a Google Form to neurosurgeons and neurosurgical trainees in neurosurgery training centers in sub-Saharan Africa; responses were accepted from September 9 to October 23, 2022. Statistical analysis was performed using Microsoft Excel and JAMOVI 3.2. RESULTS All 44 centers from 17 countries responded. Most of the respondents were neurosurgery residents (n = 30; 68.18%). The level of training on clipping was basic after completing the residency program (n = 18; 40.91%). Twenty respondents (45.45%) identified that fellowships on aneurysmal clipping and endovascular treatment are offered abroad. Thirteen participants (29.55%) indicated that endovascular treatment is available at their institutions. The most common challenges with lack of training for neurosurgical aneurysm clipping were scarce scholarship and collaboration with training centers from high-income countries (n = 33; 75%). The availability of intensive care unit beds also contributed to the presence of neurosurgical training of aneurysm clipping (12.1 ± 3.67 vs. 9.29 ± 5.82; P = 0.05). CONCLUSIONS In sub-Saharan African countries, the lack of collaborations with high-income countries for training through fellowships of young neurosurgeons for aneurysm repair seems to be the most important challenge that should be overcome.
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Affiliation(s)
- Yao Christian Hugues Dokponou
- Department of Research, Sub-Saharan African Future Neurosurgeons Association (SAFNA), Cotonou, Benin; Department of Neurosurgery, Centre National Hospitalier Universitaire Hubert Koutoukou MAGA, Cotonou, Benin.
| | - Thierry Alihonou
- Department of Research, Sub-Saharan African Future Neurosurgeons Association (SAFNA), Cotonou, Benin; Department of Neurosurgery, Centre National Hospitalier Universitaire Hubert Koutoukou MAGA, Cotonou, Benin
| | | | | | - Arsene Daniel Nyalundja
- Department of Research, Sub-Saharan African Future Neurosurgeons Association (SAFNA), Cotonou, Benin; Center for Tropical Diseases and Global Health (CTDGH), Faculty of Medicine, Université Catholique de Bukavu, Democratic Republic of Congo
| | - Mèhomè Wilfried Dossou
- Department of Research, Sub-Saharan African Future Neurosurgeons Association (SAFNA), Cotonou, Benin
| | - Roméo Bujiriri Murhega
- Department of Research, Sub-Saharan African Future Neurosurgeons Association (SAFNA), Cotonou, Benin
| | - Laté Dzidoula Lawson
- Department of Research, Sub-Saharan African Future Neurosurgeons Association (SAFNA), Cotonou, Benin
| | | | - Nicaise Agada Kpègnon
- Department of Research, Sub-Saharan African Future Neurosurgeons Association (SAFNA), Cotonou, Benin
| | - Nourou Dine Adeniran Bankole
- Department of Research, Sub-Saharan African Future Neurosurgeons Association (SAFNA), Cotonou, Benin; Clinical Investigation Center (CIC), 1415, INSERM, Department of Interventional Neuroradiology, Tours University Hospital, Tours, France
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5
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Śliwczyński A, Jewczak M, Dorobek M, Furlepa K, Gołębiak I, Skibińska E, Sarzyńska-Długosz I. An Analysis of the Incidence and Cost of Intracranial Aneurysm and Subarachnoid Haemorrhage Treatment between 2013 and 2021. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3828. [PMID: 36900834 PMCID: PMC10001767 DOI: 10.3390/ijerph20053828] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/09/2023] [Accepted: 02/18/2023] [Indexed: 06/18/2023]
Abstract
The incidence of unruptured intracranial aneurysms (UIAs) amounts to 3.2% among adults. The annual risk of aneurysm rupture is 2-10% and it results in subarachnoid haemorrhage (SAH). The aim of this study is to assess changes in the incidence of unruptured intracranial aneurysms and subarachnoid haemorrhages in Poland between 2013 and 2021 and the cost associated with their in-hospital treatment in the acute phase. The analysis was based on the National Health Fund database. Patients diagnosed with UIA and SAH and hospitalised between 2013 and 2021 were chosen. The statistical analysis was performed with an assumed significance level of α = 0.05. The ratio between the prevalence of SAH and UIA diagnoses was 4:6. The proportion of women in relation to men was higher in both diagnoses. The highest proportions of patients with diagnoses SAH and UIA were found in highly urbanised provinces. The value of medical services in 2021 compared to 2013 increased by 81.8%. The highest values in this period were recorded in Mazowieckie province, and the lowest were recorded in Opolskie province. The overall number of patients hospitalised with diagnosis of UIA or SAH did not decrease, but the risk of aneurysm rupture probably decreased, which resulted in lower incidence of SAH in subsequent years of observation. The recorded changes in the dynamics of the value of medical services per patient or per hospitalisation largely coincided. However, it is difficult to speculate on expected value levels as not all provinces showed linear changes in the value of services provided.
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Affiliation(s)
| | - Maciej Jewczak
- Department of Operations Research, Faculty of Economics and Sociology, University of Lodz, 90-214 Lodz, Poland
| | - Małgorzata Dorobek
- Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland
| | - Kamila Furlepa
- Faculty of Medicine, Lazarski University, 02-662 Warsaw, Poland
| | | | - Edyta Skibińska
- Hospital and Healthcare Management, College of Business Administration, American University in the Emirates, Dubai P.O. Box 503000, United Arab Emirates
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Bock LA, Noben CY, van Mook WN, de Ridder IR, van Zwam WH, Schenck HE, Haeren RH, Essers BA. Endovascular treatment and neurosurgical clipping in subarachnoid hemorrhage: a systematic review of economic evaluations. J Neurosurg Sci 2023; 67:18-25. [PMID: 35147403 DOI: 10.23736/s0390-5616.21.05503-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION There are two treatment modalities for aneurysmal subarachnoid hemorrhage: endovascular treatment (EVT) and neurosurgical clipping. Results of economic evaluations are needed to gain insight into the relationship between clinical effectiveness and costs of these treatment modalities. This important information can inform both clinical decision-making processes and policymakers in facilitating Value-Based Healthcare. EVIDENCE ACQUISITION Databases (PubMed, Embase, Cochrane Library, the Centre for Reviews and Dissemination, EBSCO, and Web of Science) were searched for studies published until October 2020 that had performed economic evaluations in aneurysmal subarachnoid hemorrhage patients by comparing EVT with neurosurgical clipping. The quality of reporting and methodology of these evaluations was assessed using the associated instruments (i.e. CHEERS statement and CHEC-list, respectively). EVIDENCE SYNTHESIS A total of 6 studies met the inclusion criteria. All included studies reported both effects and costs, however five did not relate effects to costs. Only one study related effects directly to costs, thus conducted a full economic evaluation. The reporting quality scored 81% and the methodological quality scored 30%. CONCLUSIONS The quality of published cost-effectiveness studies on the treatment of aneurysmal subarachnoid hemorrhage is poor. Six studies reported both outcomes and costs, however only one study performed a full economic evaluation comparing EVT to neurosurgical clipping. Although the reporting quality was sufficient, the methodological quality was poor. Further research that relates health-related quality of life measures to costs of EVT and neurosurgical clipping is required - specifically focusing on both reporting and methodological quality. Different subgroup analyses and modeling could also enhance the findings.
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Affiliation(s)
- Lotte A Bock
- Academy of Postgraduate Medical Education, Maastricht University Medical Center, Maastricht, the Netherlands - .,School of Health Professions Education, University of Maastricht, Maastricht, the Netherlands -
| | - Cindy Y Noben
- Academy of Postgraduate Medical Education, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Walther N van Mook
- Academy of Postgraduate Medical Education, Maastricht University Medical Center, Maastricht, the Netherlands.,School of Health Professions Education, University of Maastricht, Maastricht, the Netherlands.,Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Inger R de Ridder
- Department of Neurology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Hanna E Schenck
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Roel H Haeren
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Brigitte A Essers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
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Nasra M, Weerakkody D, Maingard JT, Hall J, Mitreski G, Kok HK, Smith PD, Russell JH, Jhamb A, Brooks DM, Asadi H. A Systematic Review of Neuropsychological Outcomes After Treatment of Intracranial Aneurysms. Neurosurgery 2022; 91:831-841. [PMID: 36239513 DOI: 10.1227/neu.0000000000002147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/12/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage is a cause of profound morbidity and mortality. Its effects extend beyond functional neurological status to neurocognitive and psychological functioning. Endovascular treatment is becoming more prevalent after increasing evidence for its safety and efficacy; however, there is a relative paucity of evidence specific to neurocognitive status after treatment. OBJECTIVE To assess and compare neuropsychological outcomes after the treatment of ruptured and unruptured intracranial aneurysms. METHODS A systematic review of the literature was conducted searching for articles assessing the neuropsychological and cognitive outcomes after the treatment of ruptured and unruptured intracranial aneurysms. Inclusion criteria were English language, publication between January 2000 and October 2020, and discussion of neuropsychological outcomes in adequate detail. Outcomes were categorized into 8 domains: 5 Neurocognitive (Language, Executive Function, Complex Attention, Memory and Learning, and Perceptual motor function), Intelligence Quotient, Affect, and Quality of Life. RESULTS Twenty-four articles were included comprising 2236 patients (924 surgical clipping, 1095 endovascular coiling, and 217 controls). These studies reported that most tests revealed no significant difference [n = 356/421 (84.56%)] between treatment modalities. More studies reported significantly superior test scores in the fields of language, executive function, and memory and learning after coiling [n = 53/421 tests (12.59%)] compared with clipping [n = 12/421 tests (2.85%)]. CONCLUSION The current available data and published studies demonstrate a trend toward improved neurocognitive and psychological outcomes after endovascular treatment. Although these findings should be considered when deciding on the optimal treatment method for each patient, drawing definitive conclusions is difficult because of heterogeneity between patients and studies.
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Affiliation(s)
| | | | - Julian Tam Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia.,Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Australia.,Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Jonathan Hall
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Goran Mitreski
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service, Northern Health, Epping, Victoria, Australia
| | - Paul D Smith
- Department of Neurosurgery, St Vincent's Hospital, Fitzroy, Victoria, Melbourne, Australia.,Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Melbourne
| | - Jeremy H Russell
- Department of Neurosurgery, Austin Health, Heidelberg, Victoria, Australia
| | - Ashu Jhamb
- Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Duncan Mark Brooks
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Australia.,School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia.,Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Australia.,School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
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8
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Ahmed A, Ahmed Y, Duah-Asante K, Lawal A, Mohiaddin Z, Nawab H, Tang A, Wang B, Miller G, Malawana J. A cost-utility analysis comparing endovascular coiling to neurosurgical clipping in the treatment of aneurysmal subarachnoid haemorrhage. Neurosurg Rev 2022; 45:3259-3269. [PMID: 36056977 PMCID: PMC9492573 DOI: 10.1007/s10143-022-01854-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 02/03/2023]
Abstract
Endovascular coiling (EC) has been identified in systematic reviews and meta-analyses to produce more favourable clinical outcomes in comparison to neurosurgical clipping (NC) when surgically treating a subarachnoid haemorrhage from a ruptured aneurysm. Cost-effectiveness analyses between both interventions have been done, but no cost-utility analysis has yet been published. This systematic review aims to perform an economic analysis of the relative utility outcomes and costs from both treatments in the UK. A cost-utility analysis was performed from the perspective of the National Health Service (NHS), over a 1-year analytic horizon. Outcomes were obtained from the randomised International Subarachnoid Aneurysm Trial (ISAT) and measured in terms of the patient's modified Rankin scale (mRS) grade, a 6-point disability scale that aims to quantify a patient's functional outcome following a stroke. The mRS score was weighted against the Euro-QoL 5-dimension (EQ-5D), with each state assigned a weighted utility value which was then converted into quality-adjusted life years (QALYs). A sensitivity analysis using different utility dimensions was performed to identify any variation in incremental cost-effectiveness ratio (ICER) if different input variables were used. Costs were measured in pounds sterling (£) and discounted by 3.5% to 2020/2021 prices. The cost-utility analysis showed an ICER of - £144,004 incurred for every QALY gained when EC was utilised over NC. At NICE's upper willingness-to-pay (WTP) threshold of £30,000, EC offered a monetary net benefit (MNB) of £7934.63 and health net benefit (HNB) of 0.264 higher than NC. At NICE's lower WTP threshold of £20,000, EC offered an MNB of £7478.63 and HNB of 0.374 higher than NC. EC was found to be more 'cost-effective' than NC, with an ICER in the bottom right quadrant of the cost-effectiveness plane-indicating that it offers greater benefits at lower costs. This is supported by the ICER being below the NICE's threshold of £20,000-£30,000 per QALY, and both MNB and HNB having positive values (> 0).
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Affiliation(s)
- Ayla Ahmed
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Yonis Ahmed
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Kwaku Duah-Asante
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Abayomi Lawal
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Zain Mohiaddin
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Hasan Nawab
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Alexis Tang
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Brian Wang
- Department of Metabolism, Digestion and Reproduction, Imperial College Healthcare Trust, London, UK.
- Centre for Digital Health and Education Research, School of Medicine, University of Central Lancashire, Preston, UK.
| | - George Miller
- Centre for Digital Health and Education Research, School of Medicine, University of Central Lancashire, Preston, UK
| | - Johann Malawana
- Centre for Digital Health and Education Research, School of Medicine, University of Central Lancashire, Preston, UK
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9
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Lee SH, Park JS. Outcome of ruptured anterior communicating artery aneurysm treatment compared between surgical clipping and endovascular coiling: A single-center analysis. Medicine (Baltimore) 2022; 101:e30754. [PMID: 36197262 PMCID: PMC9509031 DOI: 10.1097/md.0000000000030754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The optimal treatment modality for ruptured anterior communicating artery (ACoA) aneurysms is unclear. Therefore, in this study, we aimed to compare the outcomes of endovascular coiling and surgical clipping to treat ruptured ACoA aneurysms. A retrospective analysis of 213 consecutive patients with ruptured AcoA aneurysms, who were treated with coiling or clipping between January 2010 and December 2020, was conducted. Of the 213 patients, 94 and 119 underwent clipping and coiling, respectively. The mean age was higher in the coiling group than in the clipping group (60.3 ± 13.2 vs. 53.5 ± 13.4, P < .001). The mean diameter of the aneurysmal neck was larger in the clipping group (3.4 mm vs. 3.0 mm, P = .022), whereas the dome-to-neck ratio (1.53 ± 0.52 vs. 1.70 ± 0.60, P = .031) and aspect ratio (1.67 ± 0.51 vs. 1.92 ± 0.77, P = .005) were larger in the coiling group. The prevalence of vasospasm was higher in the clipping than in the coiling group (42.6% vs. 26.9%, P = .016). The coiling group had a shorter mean intensive care unit hospitalization (18.3 vs. 12.1, P = .002) and more frequently showed favorable outcomes (Glasgow Outcome Scale 4, 5; 57.4% vs 73.1%, P = .016) compared to the clipping group. Multivariable logistic analysis showed that good initial WFNS grade (odds ratio [OR] = 6.69, 95% confidence interval [CI]: 2.69-16.65, P < .001), treatment with coiling (OR = 3.67, 95% CI: 1.70-7.90, P = .001), and absence of the need for cerebrospinal fluid diversion (OR = 5.21, 95% CI: 2.38-11.39, P < .001) were independent predictors of favorable outcomes in patients with ruptured ACoA aneurysms. Ruptured ACoA aneurysms can be safely and effectively treated using both clipping and coiling modalities. However, it may be beneficial to consider coiling as the first option for treating these aneurysms.
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Affiliation(s)
- Sang Houn Lee
- Department of Neurosurgery and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeollabuk-do, Republic of Korea
| | - Jung Soo Park
- Department of Neurosurgery and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeollabuk-do, Republic of Korea
- * Correspondence: Jung Soo Park, Department of Neurosurgery and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, 567 Baekje-daero, deokjin-gu, Jeonju-si, Jeollabuk-do, 561-756, Republic of Korea (e-mail: )
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10
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Labib MA, Rumalla K, Karahalios K, Srinivasan VM, Nguyen CL, Rahmani R, Catapano JS, Zabramski JM, Lawton MT. Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis. Neurosurgery 2022; 91:470-476. [PMID: 35876676 DOI: 10.1227/neu.0000000000002061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 04/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center. METHODS All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. RESULTS Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance. CONCLUSION Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.
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Affiliation(s)
- Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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11
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Park SW, Lee JY, Heo NH, Han JJ, Lee EC, Hong DY, Lee DH, Lee MR, Oh JS. Short- and long-term mortality of subarachnoid hemorrhage according to hospital volume and severity using a nationwide multicenter registry study. Front Neurol 2022; 13:952794. [PMID: 35989903 PMCID: PMC9389169 DOI: 10.3389/fneur.2022.952794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/11/2022] [Indexed: 12/27/2022] Open
Abstract
Introduction Recent improvements in treatment for subarachnoid hemorrhage (SAH) have decreased the mortality rates; however, the outcomes of SAH management are dependent on many other factors. In this study, we used nationwide, large-scale, observational data to investigate short- and long-term mortality rates after SAH treatment and the influence of patient severity and hospital volume. Patients and methods We selected patients with SAH treated with clipping and coiling from the South Korean Acute Stroke Assessment Registry. High- and low-volume hospitals performed ≥20 clipping and coiling procedures and <20 clipping and coiling procedures per year, respectively. Short- and long-term mortality were tracked using data from the Health Insurance Review and Assessment Service. Results Among 2,634 patients treated using clipping and coiling, 1,544 (58.6%) and 1,090 (41.4%) were hospitalized in high- and low-volume hospitals, respectively, and 910 (34.5%) and 1,724 (65.5%) were treated with clipping and coiling, respectively. Mortality rates were 13.5, 14.4, 15.2, and 16.1% at 3 months, 1, 2, and 4 years, respectively. High-volume hospitals had a significantly lower 3-month mortality rate. Patients with mild clinical status had a significantly lower 3-month mortality rate in high-volume hospitals than in low-volume hospitals. Patients with severe clinical status had significantly lower 1- and 2-year mortality rates in high-volume hospitals than in low-volume hospitals. Conclusion Short- and long-term mortality in patients with SAH differed according to hospital volume. In the modern endovascular era, clipping and coiling can lead to better outcomes in facilities with high stroke-care capabilities.
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Affiliation(s)
- Sang-Won Park
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - Ji Young Lee
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - Nam Hun Heo
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - James Jisu Han
- Department of Molecular Biophysics and Biochemistry, Yale University, New Haven, CT, United States
| | - Eun Chae Lee
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - Dong-Yong Hong
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - Dong-Hun Lee
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
| | - Man Ryul Lee
- Soonchunhyang Institute of Medi-Bio Science (SIMS), Soonchunhyang University, Cheonan, South Korea
- *Correspondence: Man Ryul Lee
| | - Jae Sang Oh
- Department of Neurosurgery, College of Medicine, Cheonan Hospital, Soonchunhyang University, Cheonan, South Korea
- Jae Sang Oh
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Duangthongphon P, Kitkhuandee A, Munkong W, Limwattananon P, Waleekhachonloet O, Rattanachotphanit T, Limwattananon S. Cost-effectiveness analysis of endovascular coiling and neurosurgical clipping for aneurysmal subarachnoid hemorrhage in Thailand. J Neurointerv Surg 2021; 14:942-947. [PMID: 34544826 DOI: 10.1136/neurintsurg-2021-017970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/27/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND For patients with aneurysmal subarachnoid hemorrhage (aSAH), the Universal Coverage Scheme in Thailand covers the full costs of surgical and endovascular procedures except for those of embolization coils and assisting devices. Costs and effectiveness were compared between endovascular coiling and neurosurgical clipping to inform reimbursement policy decisions. METHODS Costs and quality-adjusted life years (QALYs) were compared between coiling and clipping using the decision tree and Markov models. Mortality and functional outcomes of clipping were derived from national and hospital databases, and relative efficacies of coiling were obtained from meta-analyses of randomized controlled trials. Risks of rebleeding were abstracted from the International Subarachnoid Aneurysm Trial. Costs of the primary treatments, retreatments and follow-up care as well as utilities were obtained from hospital-based data. Non-health and indirect costs were abstracted from standard cost lists. RESULTS Coiling and clipping contributed 10.59 and 9.28 QALYs to patients aged in their 50s. Under the societal and healthcare perspectives, the incremental costs incurred by coiling compared with clipping were US$1923 and $4343, respectively, which were equal to the incremental cost-effectiveness ratio of US$1470 and $3321 per QALY gained, respectively. Coiling became a cost-saving option when the costs of coil devices were reduced by 65.7%. At the country's cost-effectiveness threshold of US$5156, the probability of coiling being cost-effective was 71.3% and 65.6%, under the societal and healthcare perspectives, respectively. CONCLUSION Endovascular treatment for aSAH is cost-effective and this evidence supports coverage by national insurance.
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Affiliation(s)
| | - Amnat Kitkhuandee
- Department of Surgery, Khon Kaen University Faculty of Medicine, Khon Kaen, Thailand
| | - Waranon Munkong
- Department of Radiology, Khon Kaen University Faculty of Medicine, Khon Kaen, Thailand
| | | | | | | | - Supon Limwattananon
- Division of Social and Administrative Pharmacy, Khon Kaen University Faculty of Pharmaceutical Sciences, Khon Kaen, Thailand
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Lo YL, Bih ZL, Yu YH, Li MC, Chen HM, Wu SY. Long-Term Medical Resource Consumption between Surgical Clipping and Endovascular Coiling for Aneurysmal Subarachnoid Hemorrhage: A Propensity Score-Matched, Nationwide, Population-Based Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115989. [PMID: 34199671 PMCID: PMC8199713 DOI: 10.3390/ijerph18115989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 12/21/2022]
Abstract
Purpose: To estimate long-term medical resource consumption in patients with subarachnoid aneurysmal hemorrhage (SAH) receiving surgical clipping or endovascular coiling. Patients and methods: From Taiwan’s National Health Insurance Research Database, we enrolled patients with aneurysmal SAH who received clipping or coiling. After propensity score matching and adjustment for confounders, a generalized linear mixed model was used to determine significant differences in the accumulative hospital stay (days), intensive care unit (ICU) stay, and total medical cost for aneurysmal SAH, as well as possible subsequent surgical complications and recurrence. Results: The matching process yielded a final cohort of 8102 patients (4051 and 4051 in endovascular coil embolization and surgical clipping, respectively) who were eligible for further analysis. The mean accumulative hospital stay significantly differed between coiling (31.2 days) and clipping (46.8 days; p < 0.0001). After the generalized linear model adjustment of gamma distribution with a log link, compared with the surgical clipping procedure, the adjusted odds ratios (aOR; 95% confidence interval [CI]) of the medical cost of accumulative hospital stay for the endovascular coil embolization procedure was 0.63 (0.60, 0.66; p < 0·0001). The mean accumulative ICU stay significantly differed between the coiling and clipping groups (9.4 vs. 14.9 days; p < 0.0001). The aORs (95% CI) of the medical cost of accumulative ICU stay in the endovascular coil embolization group was 0.61 (0.58, 0.64; p < 0.0001). The aOR (95% CI) of the total medical cost of index hospitalization in the endovascular coil embolization group was 0·85 (0.82, 0.87; p < 0.0001). Conclusions: Medical resource consumption in the coiling group was lower than that in the clipping group.
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Affiliation(s)
- Yang-Lan Lo
- Department of Neurosurgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan;
| | - Zen Lang Bih
- Department of Emergency Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan;
| | - Ying-Hui Yu
- Department of Colorectal Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan; (Y.-H.Y.); (M.-C.L.)
| | - Ming-Chang Li
- Department of Colorectal Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan; (Y.-H.Y.); (M.-C.L.)
| | - Ho-Min Chen
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung 413, Taiwan;
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan
| | - Szu-Yuan Wu
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung 413, Taiwan;
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan
- Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung 413, Taiwan
- Graduate Institute of Business Administration, Fu Jen Catholic University, Taipei 242062, Taiwan
- Centers for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan
- Correspondence: or
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14
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Dandurand C, Zhou L, Prakash S, Redekop G, Gooderham P, Haw CS. Cost-effectiveness analysis in patients with an unruptured cerebral aneurysm treated with observation or surgery. J Neurosurg 2021; 135:1608-1616. [PMID: 33962376 DOI: 10.3171/2020.11.jns202892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The main goal of preventive treatment of unruptured intracranial aneurysms (UIAs) is to avoid the morbidity and mortality associated with aneurysmal subarachnoid hemorrhage. A comparison between the conservative approach and the surgical approach combining endovascular treatment and microsurgical clipping is currently lacking. This study aimed to conduct an updated evaluation of cost-effectiveness comparing the two approaches in patients with UIA. METHODS A decision tree with a Markov model was developed. Quality-adjusted life-years (QALYs) associated with living with UIA before and after treatment were prospectively collected from a cohort of patients with UIA at a tertiary center. Other inputs were obtained from published literature. Using Monte Carlo simulation for patients aged 55, 65, and 75 years, the authors modeled the conservative management in comparison with preventive treatment. Different proportions of endovascular and microsurgical treatment were modeled to reflect existing practice variations between treatment centers. Outcomes were assessed in terms of QALYs. Sensitivity analyses to assess the model's robustness and completed threshold analyses to examine the influence of input parameters were performed. RESULTS Preventive treatment of UIAs consistently led to higher utility. Models using a higher proportion of endovascular therapy were more cost-effective. Models with older cohorts were less cost-effective than those with younger cohorts. Treatment was cost-effective (willingness to pay < 100,000 USD/QALY) if the annual rupture risk exceeded a threshold between 0.8% and 1.9% in various models based on the proportion of endovascular treatment and cohort age. A higher proportion of endovascular treatments and younger age lowered this threshold, making the treatment of aneurysms with a lower risk of rupture more cost-effective. CONCLUSIONS Preventive treatment of aneurysms led to higher utility compared with conservative management. Models with a higher proportion of endovascular treatment and younger patient age were most cost-effective.
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Affiliation(s)
- Charlotte Dandurand
- Faculty of Medicine, Divisions of1Neurosurgery and
- 2T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Lily Zhou
- 2T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- 3Neurology, University of British Columbia, Vancouver, Canada; and
| | | | - Gary Redekop
- Faculty of Medicine, Divisions of1Neurosurgery and
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15
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Lee KS, Zhang JJY, Nguyen V, Han J, Johnson JN, Kirollos R, Teo M. The evolution of intracranial aneurysm treatment techniques and future directions. Neurosurg Rev 2021; 45:1-25. [PMID: 33891216 PMCID: PMC8827391 DOI: 10.1007/s10143-021-01543-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/21/2021] [Accepted: 04/07/2021] [Indexed: 01/06/2023]
Abstract
Treatment techniques and management guidelines for intracranial aneurysms (IAs) have been continually developing and this rapid development has altered treatment decision-making for clinicians. IAs are treated in one of two ways: surgical treatments such as microsurgical clipping with or without bypass techniques, and endovascular methods such as coiling, balloon- or stent-assisted coiling, or intravascular flow diversion and intrasaccular flow disruption. In certain cases, a single approach may be inadequate in completely resolving the IA and successful treatment requires a combination of microsurgical and endovascular techniques, such as in complex aneurysms. The treatment option should be considered based on factors such as age; past medical history; comorbidities; patient preference; aneurysm characteristics such as location, morphology, and size; and finally the operator’s experience. The purpose of this review is to provide practicing neurosurgeons with a summary of the techniques available, and to aid decision-making by highlighting ideal or less ideal cases for a given technique. Next, we illustrate the evolution of techniques to overcome the shortfalls of preceding techniques. At the outset, we emphasize that this decision-making process is dynamic and will be directed by current best scientific evidence, and future technological advances.
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Affiliation(s)
- Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK. .,Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK.
| | - John J Y Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vincent Nguyen
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK.,Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Julian Han
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Ramez Kirollos
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Mario Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK
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16
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Suzuki T, Genkai N, Nomura T, Abe H. Assessing the Hemodynamics in Residual Cavities of Intracranial Aneurysm after Coil Embolization with Combined Computational Flow Dynamics and Silent Magnetic Resonance Angiography. J Stroke Cerebrovasc Dis 2020; 29:105290. [PMID: 32992205 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105290] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/21/2020] [Accepted: 08/26/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Metal artifacts limit computational fluid dynamics analysis after coil embolization. Silent magnetic resonance angiography reduces metal artifacts and improves visualization of the residual cavity of coil-embolized aneurysms. This study investigated the flow dynamics of the residual cavity after coil embolization using silent magnetic resonance angiography and computational fluid dynamics to elucidate the hemodynamic characteristics of recanalization. METHODS Twenty internal carotid-posterior communicating aneurysm cases treated with coil embolization and without stent assistance were followed up (mean±standard deviation, 13.0±6.1 months) and assessed using silent magnetic resonance angiography. The hemodynamic characteristics of the residual cavities in both types of aneurysms were compared between neck remnants, which persisted for >12 months (NR group), and those treated with coil compaction-induced body filling (BF group). Computational fluid dynamics analysis of each aneurysm was performed using morphological data obtained from silent magnetic resonance angiography. Pressure, pressure difference, normalized wall shear stress, and flow velocity were measured. RESULTS The residual cavity was well-visualized using silent magnetic resonance angiography and compared with those imaged using conventional time-of-flight magnetic resonance angiography, and eight internal carotid-posterior communicating aneurysms with neck remnants and body filling were investigated. The maximum pressure area was localized to the aneurysm wall in the NR group (n=4) and to sides of the coil surface in the BF group (n=4). No significant differences were observed for each hemodynamic parameter. CONCLUSIONS Combination of silent magnetic resonance angiography and computational fluid dynamics helps to understand the hemodynamic characteristics of residual cavity in coil- embolized aneurysms. The flow-impingement zone at the coil surface (maximum pressure area) may influence the risk for future coil compaction.
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Affiliation(s)
- Tomoaki Suzuki
- Department of Neurosurgery, Tachikawa General Hospital, 1-24 Asahioka, Nagaoka 940-8621, Japan; Department of Neurosurgery, Brain Research Institute, Niigata University, 1-757 Asahimachi-Dori, Niigata 951-8585, Japan.
| | - Nobuyuki Genkai
- Department of Neurosurgery, Tachikawa General Hospital, 1-24 Asahioka, Nagaoka 940-8621, Japan
| | - Toshiharu Nomura
- Department of Neurosurgery, Tachikawa General Hospital, 1-24 Asahioka, Nagaoka 940-8621, Japan
| | - Hiroshi Abe
- Department of Neurosurgery, Tachikawa General Hospital, 1-24 Asahioka, Nagaoka 940-8621, Japan
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17
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Outcome of Microsurgical Clipping for Multiple Versus Single Intracranial Aneurysms: A Single-Institution Retrospective Comparative Cohort Study. World Neurosurg 2020; 143:e590-e603. [PMID: 32781147 DOI: 10.1016/j.wneu.2020.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the results of microsurgical clipping for single intracranial aneurysm (SIA) and multiple intracranial aneurysms (MIA) and compare the outcomes. METHODS All patients who underwent surgery for intracranial aneurysm (IA) at our institution over a 3-year period (June 2013 to May 2016) were included in this study. RESULTS A total of 157 patients with 225 IAs were included. Forty-one of these patients had MIA (109 IAs, mean, 2.7 ± 1.2; range, 2-7), and remaining 116 had SIA. In the patients with MIA, all aneurysms were secured during the same admission whenever possible. Depending on the locations of the IAs and condition of brain during surgery (tense/lax), all aneurysms were secured on same day (in a single session, single or multiple craniotomy in 28 patients) or on different days (multiple sessions in 13 patients). Postoperative control angiography (DSA) before discharge could be done for 216 aneurysms (MIA, n = 105; SIA, n = 111). Successful occlusion of the aneurysm from circulation was noted in 96.2% (101/105) of MIA and 93.7% (104/111) of SIA. Follow-up of 6 months or longer was available for 146 patients. A modified Rankin Scale score ≤2 was considered a good outcome. Univariate analysis of the entire group revealed no significant difference in clinical outcomes between patients with SIA and MIA both at discharge (good outcome: MIA, 82.9%; SIA, 93.1%; P = 0.068) and at a final follow-up of ≥6 months (good outcome: MIA, 87.2%; SIA, 94.4%; P = 0.164). Clipping for MIA was not associated with poor outcome in multivariate analysis. CONCLUSIONS Comparable clinical outcomes and high rates of complete aneurysm occlusion following microsurgical clipping can be expected in patients with SIA and patients with MIA.
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Figueroa-Sanchez JA, Ferrigno AS, Hinojosa-González DE, Salgado-Garza G, Martinez HR, Caro-Osorio E, Garza-Garcia JG. Cost analysis of materials used in the endovascular treatment of unruptured intracranial aneurysms in Mexico. Interv Neuroradiol 2020; 26:476-482. [PMID: 32316812 PMCID: PMC7446595 DOI: 10.1177/1591019920920954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/06/2020] [Accepted: 03/07/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To prevent the potentially fatal consequences of intracranial aneurysmal rupture, exclusion from the circulation can be achieved through an endovascular approach. However, the elevated cost of such procedures can be prohibitive for patients in low resource settings. The objective of this study is to identify the factors that modify the cost of the materials used for endovascular treatment of unruptured intracranial aneurysms. METHODS Medical records of patients who underwent an endovascular treatment for unruptured intracranial aneurysms between June 2013 and June 2019 in a hospital located in Northeast Mexico were reviewed. Descriptive statistics of the cost of consumable materials used during the procedure was performed, and a regression model was undertaken to examine potential associations between the studied variables and total cost of the intervention. RESULTS A total of 128 patients were included in this analysis. The average intervention cost was $21,687.22 USD. The variables associated with increased material cost were aneurysm size (p = 0.03), aneurysm neck size (p < 0.001), and aneurysm localization in the cavernous segment of the internal carotid artery (p = 0.01). Other variables such as patient age and sex, other aneurysm localizations, laterality of the aneurysm, performing neurointerventionalist, and presence of intervention complications were not statistically significant. CONCLUSIONS To our knowledge, this is the first study that examines the variables associated with the material cost of endovascular treatment of unruptured intracranial aneurysms. Awareness of which elements are important drivers of materials' costs provides a strategic advantage when making hospital administrative decisions and attempting to improve access to endovascular treatment in countries of low income.
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Affiliation(s)
- Jose A Figueroa-Sanchez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
- Instituto de Neurologia y Neurocirugia, Hospital Zambrano Hellion, Tecnologico de Monterrey, San Pedro Garza Garcia, Nuevo Leon, Mexico
- Tecnologico de Monterrey, EGADE Business School, San Pedro Garza García, Mexico
| | - Ana S Ferrigno
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | | | - Gustavo Salgado-Garza
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Hector R Martinez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
- Instituto de Neurologia y Neurocirugia, Hospital Zambrano Hellion, Tecnologico de Monterrey, San Pedro Garza Garcia, Nuevo Leon, Mexico
| | - Enrique Caro-Osorio
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
- Instituto de Neurologia y Neurocirugia, Hospital Zambrano Hellion, Tecnologico de Monterrey, San Pedro Garza Garcia, Nuevo Leon, Mexico
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Wilde H, Twitchell S, Reese J, Guan J, Eli IM, Karsy M, Taussky P, Grandhi R, Schmidt RH, Couldwell WT. Evaluation of disease severity and treatment intensity as cost drivers for ruptured intracranial aneurysms. Acta Neurochir (Wien) 2020; 162:157-167. [PMID: 31811467 DOI: 10.1007/s00701-019-04153-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 11/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies have not evaluated the impact of illness severity and postrupture procedures in the cost of care for intracranial aneurysms. We hypothesize that the severity of aneurysm rupture and the aggressiveness of postrupture interventions play a role in cost. METHODS The Value Driven Outcomes database was used to assess direct patient cost during the treatment of ruptured intracranial aneurysm with clipping, coiling, and Pipeline flow diverters. RESULTS One hundred ninety-eight patients (mean age 52.8 ± 14.1 years; 40.0% male) underwent craniotomy (64.6%), coiling (26.7%), or flow diversion (8.6%). Coiling was 1.4× more expensive than clipping (p = .005) and flow diversion was 1.7× more expensive than clipping (p < .001). More severe illness as measured by American Society of Anesthesia, Hunt/Hess, and Fisher scales incurred higher costs than less severe illness (p < .05). Use of a lumbar drain protocol to reduce subarachnoid hemorrhage and use of an external ventricular drain to manage intracranial pressure were associated with reduced (p = .05) and increased (p < .001) total costs, respectively. Patients with severe vasospasm (p < .005), those that received shunts (p < .001), and those who had complications (p < .001) had higher costs. Multivariate analysis showed that procedure type, length of stay, number of angiograms, vasospasm severity, disposition, and year of treatment were independent predictors of cost. CONCLUSIONS These results show for the first time that disease and vasospasm severity and intensity of treatment directly impact the cost of care for patients with aneurysms in the USA. Strategies to alter these variables may prove important for cost reduction.
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Affiliation(s)
- Herschel Wilde
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Spencer Twitchell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Jared Reese
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Ilyas M Eli
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Richard H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA.
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Surgical Versus Endovascular Management of Ruptured and Unruptured Intracranial Aneurysms: Emergent Issues and Future Directions. World Neurosurg 2019; 136:17-27. [PMID: 31899398 DOI: 10.1016/j.wneu.2019.12.127] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/20/2019] [Accepted: 12/21/2019] [Indexed: 12/25/2022]
Abstract
Ideal management of unruptured intracranial aneurysms (UIAs) and ruptured intracranial aneurysms (RIAs) is a controversial issue. Over the last few decades, a significant paradigm shift has occurred away from open microsurgical clipping toward endovascular coil embolization. Multiple studies have been performed with mixed results. Some studies suggest that endovascular treatment produces better clinical and functional outcomes, but is associated with increased need for retreatment. Other studies report increased durability in aneurysms treated with microsurgical clipping, but that clipping may be associated with worse functional outcomes in some cases. Further complicating the dialogue are variable costs associated with different treatment modalities, including country-dependent cost differences. Here we provide a review of some of the major studies comparing open surgery versus endovascular treatment for both RIAs and UIAs to distill their key findings and corresponding implications for clinical practice. We relate these research results to our institution's experience with RIAs and UIAs and describe our approach to treatment of these conditions. Finally, we discuss implications of the paradigm shift for both open and endovascular surgery, including educational initiatives directed toward preserving important microsurgical tenets in the setting of diminishing surgical volume.
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Twitchell S, Wilde HW, Taussky P, Karsy M, Grandhi R. Initial Treatment for Unruptured Intracranial Aneurysm and Its Follow-up: A Cost Analysis of Pipeline Flow Diverters versus Coiling. Cureus 2019; 11:e5692. [PMID: 31720160 PMCID: PMC6823005 DOI: 10.7759/cureus.5692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Purpose Intracranial aneurysms are relatively common epidemiological problems for which the surveillance, treatment, and follow-up are costly. Although multiple studies have evaluated the treatment cost of aneurysms, the follow-up costs are often not examined. In our study, we analyzed how follow-up costs after treatment affected the overall cost of different endovascular techniques for treating aneurysms. Materials and methods An institutional database was used to evaluate the upfront and follow-up costs incurred by patients who underwent elective coiling or placement of a pipeline embolization device (PED) for the treatment of unruptured intracranial aneurysms from July 2011 to December 2017. Results A total of 114 patients (coiling, n = 37; PED, n = 77 ) were included in the study. There was no significant difference among patients in mean age [61.3 (±12.8 years) vs. 57.0 (±14.5 years); probability value (p) = 0.2], sex (male: 32.4% vs. 22.1%; p = 0.2), American Society of Anesthesiologists (ASA) grade (p = 0.5), discharge disposition (p = 0.1), mean length of stay [3.1 days (±5.5) vs. 2.4 days (±2.6); p = 0.2) or follow-up period [22.7 months (±18.5) vs. 18.6 months (±14.9); p = 0.2). There were no differences in costs during admission (p = 0.5) or in follow-up (p = 0.3) between coiling and PED treatments. Initial costs were predominantly related to supplies/implants (56.1% vs. 63.7%) for both treatments. Follow-up costs mostly comprised facility costs (68.2% vs. 67.5%), and there were no differences in costs of subgroups such as supplies/implants (10.5% vs. 9.4%), imaging (17.0% vs. 17.8%), or facilties between coiling and PED. Conclusion These results suggest that the upfront and follow-up costs are mostly similar for the treatment of intracranial aneurysms irrespective of whether the providers used coiling or PED endovascular techniques. Hence, we conclude that follow-up costs should not be a deciding factor when considering these treatments.
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Affiliation(s)
- Spencer Twitchell
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
| | - Herschel W Wilde
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
| | - Philipp Taussky
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
| | - Michael Karsy
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
| | - Ramesh Grandhi
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
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Abstract
AIMS Major depressive disorders are highly prevalent in the world population, contribute substantially to the global disease burden and cause high health care expenditures. Information on the economic impact of depression, as provided by cost-of-illness (COI) studies, can support policymakers in the decision-making regarding resource allocation. Although the literature on COI studies of depression has already been reviewed, there is no quantitative estimation of depression excess costs across studies yet. Our aims were to systematically review COI studies of depression with comparison group worldwide and to assess the excess costs of depression in adolescents, adults, elderly, and depression as a comorbidity of a primary somatic disease quantitatively in a meta-analysis. METHODS We followed the PRISMA reporting guidelines. PubMed, PsycINFO, NHS EED, and EconLit were searched without limitations until 27/04/2018. English or German full-text peer-reviewed articles that compared mean costs of depressed and non-depressed study participants from a bottom-up approach were included. We only included studies reporting costs for major depressive disorders. Data were pooled using a random-effects model and heterogeneity was assessed with I2 statistic. The primary outcome was ratio of means (RoM) of costs of depressed v. non-depressed study participants, interpretable as the percentage change in mean costs between the groups. RESULTS We screened 12 760 articles by title/abstract, assessed 393 articles in full-text and included 48 articles. The included studies encompassed in total 55 898 depressed and 674 414 non-depressed study participants. Meta-analysis showed that depression was associated with higher direct costs in adolescents (RoM = 2.79 [1.69-4.59], p < 0.0001, I2 = 87%), in adults (RoM = 2.58 [2.01-3.31], p < 0.0001, I2 = 99%), in elderly (RoM = 1.73 [1.47-2.03], p < 0.0001, I2 = 73%) and in participants with comorbid depression (RoM = 1.39 [1.24-1.55], p < 0.0001, I2 = 42%). In addition, we conducted meta-analyses for inpatient, outpatient, medication and emergency costs and a cost category including all other direct cost categories. Meta-analysis of indirect costs showed that depression was associated with higher costs in adults (RoM = 2.28 [1.75-2.98], p < 0.0001, I2 = 74%). CONCLUSIONS This work is the first to provide a meta-analysis in a global systematic review of COI studies for depression. Depression was associated with higher costs in all age groups and as comorbidity. Pooled RoM was highest in adolescence and decreased with age. In the subgroup with depression as a comorbidity of a primary somatic disease, pooled RoM was lower as compared to the age subgroups. More evidence in COI studies for depression in adolescence and for indirect costs would be desirable.
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Xue T, Chen Z, Lin W, Xu J, Shen X, Wang Z. Hydrogel coils versus bare platinum coils for the endovascular treatment of intracranial aneurysms: a meta-analysis of randomized controlled trials. BMC Neurol 2018; 18:167. [PMID: 30290784 PMCID: PMC6172718 DOI: 10.1186/s12883-018-1171-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/28/2018] [Indexed: 11/30/2022] Open
Abstract
Background Recent studies have shown conflicting results regarding the effect of hydrogel coils for treating intracranial aneurysm compared to bare platinum coils. We implemented a meta-analysis to assess the value of hydrogel coils in intracranial aneurysm treatment. Methods The MEDLINE, EMBASE, and Cochrane Library databases were searched for randomized controlled trials (RCTs) which had evaluated hydrogel coils versus bare platinum coils for intracranial aneurysms. Results We pooled 1526 patients from 4 RCTs with the mean follow-up time of more than 16 months. Hydrogel coils had reductions on mid-term recurrence (RR 0.78, 95% CI 0.65 to 0.94, P = 0.008) and residual aneurysm (RR 0.71, 95% CI 0.57 to 0.88, P = 0.002), but didn’t show any significant differences in other favorable outcomes such as functional recovery, mortality and so on. In the subgroup analysis, we found that second-generation hydrogel coils might exhibit potential impacts on increasing mid-term complete occlusion (RR 1.26, 95% CI 1.07 to 1.48, P = 0.005) and decreasing residual aneurysm neck. (RR 0.54, 95% CI 0.34 to 0.86, P = 0.010). Conclusions Hydrogel coils showed no significant efficacy on functional recovery but exhibited a lower rate of recurrences and residual aneurysms in patients with intracranial aneurysms. Electronic supplementary material The online version of this article (10.1186/s12883-018-1171-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tao Xue
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China
| | - Weiwei Lin
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, 15219, USA
| | - Jiayi Xu
- Department of Ophthalmology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, Jiangsu Province, China
| | - Xuming Shen
- Department of Neurosurgery, Taicang Affiliated Hospital of Soochow University, Suzhou, 215400, Jiangsu Province, China.
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, China.
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