Predictors of acute post-thrombectomy intracranial hemorrhage expansion in anterior circulation infarcts

Analysis of selective neurocritical care admission costs following elective endovascular treatment of unruptured intracranial aneurysms

INTRODUCTION

No consensus exists on the necessity of neurocritical care unit (NCU)-level care following unruptured intracranial aneurysm (UIA) treatment. We aim to identify patients requiring NCU-level care post-treatment and determine potential cost savings utilizing a selective NCU admission protocol.

METHODS

A retrospective analysis of all UIA patients who underwent endovascular treatment at a single center from 2017-2022 was conducted. Data on demographics, preprocedural variables, radiographic features, procedural techniques, intra/postoperative events, and length of stay (LOS) were collected. Multivariable analysis was performed to identify patients requiring NCU-level care post-treatment. Cost analysis using hospital cost data (not charges/reimbursement) was performed using simulated step-down and floor protocols for patients without NCU indications following a hypothetical six-hour post-anesthesia care unit observation period.

RESULTS

Of 209 patients, 179 were discharged within 24 h and 30 had prolonged LOS. In our analysis, intra- and postoperative events independently predicted prolonged LOS. In our subanalysis, 47 patients demonstrated NCU needs: 24 with intraoperative indications, 18 with postoperative indications, and five with both. Of the 23 with postoperative indications, 20 were identified within six hours, while three were identified within six to 24 h. The median variable cost per patient for the current NCU protocol was $31,505 (IQR, $26,331-$37,053) vs. stepdown protocol $29,514 (IQR, $24,746-$35,011;p = 0.061) vs. floor protocol $26,768 (IQR, $22,214-$34,107;p < 0.001). Total variable costs were $6,211,497 for the current NCU protocol vs. $5,921,912 for the step-down protocol (4.89% savings) and $5,509,052 for the floor protocol (12.75% savings).

CONCLUSION

Most patients requiring NCU-level care following UIA treatment were identified within a six-hour postoperative window. Thus, selective NCU admission for this cohort following a six-hour observation period may be a logical avenue for cost reduction. Our analysis demonstrated 5% and 13% savings for uncomplicated patients using step-down and floor admission protocols, respectively.