Advanced Age and Post-Acute Care Outcomes After Subarachnoid Hemorrhage

Cerebral aneurysms: Germany-wide real-world outcome data of endovascular or neurosurgical treatment from 2007 to 2019

BACKGROUND

Evidence on clinical outcome after endovascular treatment (EVT) vs neurosurgical clipping of intracranial aneurysms (IAs) is based on one randomized and one pseudo-randomized trial for ruptured aneurysms. Herein, we analyze nationwide real-world hospital outcomes after EVT vs clipping of ruptured and unruptured IAs.

METHODS

This cohort study analyzed all EVT and clipping procedures for IAs in Germany between 2007 and 2019. The data basis was the billing-data of all German hospitals from the German Federal Statistical Office. EVT and clipping interventions, comorbidities, and in-hospital outcomes were identified using International Classification of Diseases (ICD) and Operation and Procedure (OPS) codes. Discharge type was used as a surrogate marker for functional independence. Poor clinical outcome at discharge was additionally defined by the dichotomous US National Inpatient Sample-Subarachnoid hemorrhage Outcome Measure score (NIH-SOM). Secondary outcomes included length of hospital stay, prolonged mechanical ventilation (>48 hour), and hospital reimbursement.

RESULTS

We analyzed 90 039 procedures (62.6% EVT, 35.52% clipping, 1.8% combined) for the treatment of IAs. After adjustment in-hospital mortality was equal after EVT compared with clipping, in ruptured IAs (adjusted OR (aOR) 0.98, p=0.707) and unruptured IAs (aOR 0.92, p=0.482). Functional independence was more likely after EVT for ruptured (aOR 0.81, p<0.001) and unruptured IAs (aOR 0.4, p<0.001). Poor clinical outcome was more likely after clipping for ruptured (aOR 0.67, p<0.001) and unruptured IAs (aOR 0.56, p<0.001).

CONCLUSIONS

In German clinical practice, we observed higher rates of functional independence and lower rates of poor outcomes at discharge with equal mortality for EVT.

Predictors of Time to Aneurysm Repair and Mortality in Aneurysmal Subarachnoid Hemorrhage

ABSTRACT

BACKGROUND : Prompt aneurysm repair is essential to prevent rebleeding after aneurysmal subarachnoid hemorrhage. To date, most studies on this topic have focused on 1 set of predictors (eg, hospital or patient characteristics) and on 1 outcome (either time to aneurysm repair or mortality). The purpose of this study was to test a model that includes hospital and patient characteristics as predictors of time to aneurysm repair and mortality, controlling for disease severity and comorbidity, and considering time to aneurysm repair as a potential influence in these relationships. METHODS : A sample of aneurysmal subarachnoid hemorrhage patients with a principal procedure of clipping or coiling was selected (n = 387) from a statewide administrative database for cross-sectional retrospective analysis. The primary study outcome was in-hospital mortality. Independent variables were level of stroke center, age, race, sex, and type of aneurysm repair. Hierarchical logistic regression was used to estimate the probability of in-hospital death. RESULTS : Patients who underwent a coiling procedure were more likely to be treated within the first 24 hours of admission compared with those undergoing clipping (odds ratio, 0.54; 95% CI, 0.35-0.84; P = .01). Patients treated at a certified comprehensive stroke center (CSC) had a 72% reduction in odds of death compared with those treated at primary stroke centers (odds ratio, 0.28; 95% CI, 0.10-0.77; P = .01), after controlling for disease severity and comorbid conditions. Time to aneurysm repair was not significantly associated with mortality and did not influence the relationship between hospital and patient characteristics and mortality. CONCLUSION : Our results indicate that treatment at a CSC was associated with a lower risk of in-hospital mortality. Time to aneurysm repair did not influence mortality and did not explain the mortality benefit observed in CSCs. Research is needed to explore interdisciplinary hospital factors including nursing and nurse-sensitive interventions that may explain the relationship between CSCs and mortality outcomes.

Palliative Care Involvement in Patients Hospitalized in the United States with Aneurysmal Subarachnoid Hemorrhage

Background: Aneurysmal subarachnoid hemorrhage (aSAH) has a high mortality rate and significantly impacts survivors' quality of life. Objective: To assess impact of specialty palliative care services (sPCS) among patients hospitalized with aSAH. Design: A retrospective cohort study using the National Inpatient Sample (2017-2018). Setting/Subjects: U.S. adult patients hospitalized for aSAH with and without sPCS involvement. Measurements: Mortality and health care utilization variables. Results: Among 48,050 patients with aSAH, 12.7% received sPCS input. aSAH patients with sPCS were more likely to be sicker (higher National Inpatient Sample-subarachnoid hemorrhage [NIS-SAH] severity score, p < 0.01). Patients with sPCS had a 70% in-hospital mortality rate, whereas only 9% of the rest of this cohort died during the incident hospitalization (p < 0.01). Those with sPCS involvement had shorter lengths of stay (p < 0.05) and nonsignificantly lower hospital charges. Conclusion: sPCS involvement, inferred by International Classification of Diseases, 10th Revision (ICD-10) code Z51.5, was associated with shorter length of stay and lower hospital charges among survivors, but this did not meet prespecified statistical significance. There may be significant benefits to consulting sPCS for patients hospitalized with aSAH.

Aging Patient Population With Ruptured Aneurysms: Trend Over 28 Years

BACKGROUND

Given increasing life expectancy in the United States and worldwide, the proportion of elderly patients affected by aneurysmal subarachnoid hemorrhage (aSAH) would be expected to increase.

OBJECTIVE

To determine whether an aging trend exists in the population of aSAH patients presenting to our institution over a 28-yr period.

METHODS

A prospectively maintained database of consecutive patients presenting to our institution with subarachnoid hemorrhage between January 1991 and December 2018 was utilized. The 28-yr period was categorized into 4 successive 7-yr quarter intervals. The age of patients was compared among these intervals, and yearly trends were derived using linear regression.

RESULTS

The cohort consisted of 1671 ruptured aneurysm patients with a mean age of 52.8 yr (standard deviation = 15.0 yr). Over the progressive 7-yr time intervals during the 28-yr period, there was an approximately 4-fold increase in the proportion of patients aged 80 yr or above (P < .001) and an increase in mean patient age from 51.2 to 54.6 yr (P = .002). Independent of this trend but along the same lines, there was a 29% decrease in the proportion of younger patients (<50 yr) from 49% to 35%. On linear regression, there was 1-yr increase in mean patient age per 5 calendar years (P < .001).

CONCLUSION

Analyses of aSAH patients demonstrate an increase in patient age over time with a considerable rise in the proportion of octogenarian patients and a decrease in patients younger than 50 yr. This aging phenomenon presents a challenge to the continued improvement in outcomes of aSAH patients.

Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes

BACKGROUND

Following publication of the International Subarachnoid Aneurysm Trial (ISAT), treatment paradigms for cerebral aneurysms (CAs) shifted from open surgical clipping to endovascular embolization as primary therapy in a majority of cases. However, comprehensive analyses evaluating more recent CA diagnosis patterns, patient populations and outcomes as a function of treatment modality remain rare.

METHODS

The National Inpatient Sample from 2004 to 2014 was reviewed. Aneurysmal subarachnoid hemorrhages (aSAHs) and unruptured intracranial aneurysms (UIAs) with a treatment of surgical clipping or endovascular therapy (EVT) were identified. Time trend series plots were created. Linear and logistic regressions were utilized to quantify treatment changes.

RESULTS

114 137 aSAHs and 122 916 UIAs were reviewed. aSAH (+732/year, p=0.014) and UIA (+2550/year, p<0.0001) discharges increased annually. The annual caseload of surgical clippings for aSAH decreased (-264/year, p=0.0002) while EVT increased (+366/year, p=0.0003). For UIAs, the annual caseload for surgical clipping remained stable but increased for EVT (+615/year, p<0.0001). The rate of incidentally diagnosed UIAs increased annually (+1987/year; p<0.0001). Inpatient mortality decreased for clipping (p<0.0001) and EVT in aSAH (p<0.0001) (2004 vs 2014-clipping 13% vs 11.7%, EVT 15.8% vs 12.7%). Mortality rates for clipped UIAs decreased over time (p<0.0001) and remained stable for EVT (2004 vs 2014-clipping 1.57% vs 0.40%, EVT 0.59% vs 0.52%).

CONCLUSION

Ruptured and unruptured CAs are increasingly being treated with EVT over clipping. Incidental unruptured aneurysm diagnoses are increasing dramatically. Mortality rates of ruptured aneurysms are improving regardless of treatment modality, whereas mortality in unruptured aneurysms is only improving for surgical clipping.

Thirty-Day Mortality and Survival in Elderly Patients Undergoing Neurosurgery

OBJECTIVES

With an aging population and advances in neuroanesthesia and critical care, an increasing subgroup of elderly patients have been undergoing neurosurgery. Of particular relevance is the cohort aged >80 years. The aim of the present study was to investigate the 30-day mortality and survival in this cohort after emergency and elective neurosurgery.

METHODS

We performed a retrospective cohort study of all patients aged ≥70 years who had undergone a neurosurgical procedure from 2015 to 2017. The patient demographic data were identified, and independent predictors were found using logistic regression analysis.

RESULTS

A total of 796 patients were included, of whom 622 were aged <80 years (group A) and 174 were aged >80 years (group B). Overall survival was 86.3% in group A and 79.9% in group B. The 30-day mortality between the elective (0.8%) and emergency (10.1%) patients was significantly different statistically (P < 0.001). Of the patients in groups A and B, 84.7% and 68.9% were discharged back to their usual residence, respectively. Logistic regression found emergency surgery to be an independent predictor of mortality.

CONCLUSIONS

The current model for accepting elderly patients has been associated with good overall outcomes. The elderly should not be refused neurosurgery on the basis of their age alone. However, we applied fairly strict criteria, especially for those with subarachnoid hemorrhage, which should be factored into our results.

Endovascular treatment of ruptured intracranial aneurysms in elderly patients: clinical features and treatment outcome

Management of ruptured intracranial aneurysm in elderly patients is still a major challenge in the treatment of cerebrovascular disease. This study aimed to evaluate safety and efficacy profiles of ruptured intracranial aneurysms in elderly patients treated with endovascular techniques (EVTs). We conducted a retrospective case review of 53 consecutive elderly patients with ruptured intracranial aneurysms treated by EVT between the year 2011 and 2016. The patients' angiographic outcomes, clinical outcomes, and procedure-related complications were reviewed retrospectively. Univariate and multivariate logistic analysis were applied to determine the risk factors of aneurysm recurrence and clinical prognosis. In 29 (54.7%) patients, the treatment was attempted with coiling alone. The vascular remodeled technique was applied in 24 (45.3%) patients. At a median angiographic follow-up of 9 months, 35 (67.3%) aneurysms showed stable, 9 (17.3%) were improvement, and 8 (15.4%) were recurrent. According to the multivariate analysis, the size of the aneurysm was independently associated with increased risk of aneurysm recurrence (odds ratio, 1.92; 95% confidence interval, 1.181-2.211; p = 0.006). High Hunt-Hess grade at admission was an independent predictor of poor functional outcome in the multivariate analysis (odds ratio, 5.93; 95% confidence interval, 1.878-33.63; p = 0.008). In 8 (15.1%) patients, it resulted in procedure-related complications. EVT of ruptured intracranial aneurysms in elderly patients is safe, effective, and have low recurrent rate. Recurrence after EVT for ruptured aneurysms is common in cases of large-size aneurysms. The overall clinical outcome was worst in patients presented with high Hunt-Hess grade.