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      Four-year trends in the treatment of cerebral aneurysms in Poland in 2009-2012

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          Abstract

          Background

          The dilemma concerning the appropriate treatment of the intracranial aneurysms (IAs) has not yet been resolved and still remains under fierce debate. This study refers to the recent trends in the use of and outcomes related to coiling compared with clipping for unruptured and ruptured IAs in Poland over a 4-year period.

          Methods

          The analysis refers to treatment of IAs performed in Poland between 2009-2012. Patients’ records were cross-matched by ICD-9 codes for ruptured SAH (430) or unruptured cerebral aneurysm (437.3) along with codes for clipping (39.51) and coiling (39.79, 39.72, or 39.52). Multivariable logistic regression was used to compare in-hospital deaths, hospital length of stay (LOS), therapy allocation and aneurysm locations in unruptured vs. ruptured and clipped vs. coiled groups. Differences in the number of procedures between 16 administrative regions were standardized per 100,000 people.

          Results

          In 2009-2012, 11,051 procedures were identified, including 5,968 ruptured and 5,083 unruptured aneurysms. Overall increase was 2.3 % in clipping and 13.1 % in coiling; a significant trend was found in endovascular procedures (p = 0.044). Ruptured aneurysms were clipped more frequently (OR = 1.66;); in unruptured IAs, endovascular procedure was preferred 3.5 times more than clipping. The annual in-hospital mortality was 7.6 % in clipping and 6.7 % in endovascular treatment. LOS was two times longer after clipping in unruptured aneurysms (OR = 2.013). After the procedures were standardized per 100,000 people, the average for Poland was established as 9.09 in 2009, 10.86 in 2010, 10.55 in 2011, and 11.49 in 2012. This index had the highest values in Mazovia (12.9, 2009; 15.4, 2010; 17.4, 2011; 18.6, 2012.

          Conclusions

          Data analysis revealed an increase in overall number of IAs treated in Poland between 2009-2012. A significant upward trend of endovascular procedures was found, whereas the number of clipped aneurysms remained relatively steady over the study period.

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          International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial.

          Andrew J. Molyneux, Richard Kerr, Irene Stratton … (2002)
          Endovascular detachable coil treatment is being increasingly used as an alternative to craniotomy and clipping for some ruptured intracranial aneurysms, although the relative benefits of these two approaches have yet to be established. We undertook a randomised, multicentre trial to compare the safety and efficacy of endovascular coiling with standard neurosurgical clipping for such aneurysms judged to be suitable for both treatments. We enrolled 2143 patients with ruptured intracranial aneurysms and randomly assigned them to neurosurgical clipping (n=1070) or endovascular treatment by detachable platinum coils (n=1073). Clinical outcomes were assessed at 2 months and at 1 year with interim ascertainment of rebleeds and death. The primary outcome was the proportion of patients with a modified Rankin scale score of 3-6 (dependency or death) at 1 year. Trial recruitment was stopped by the steering committee after a planned interim analysis. Analysis was per protocol. 190 of 801 (23.7%) patients allocated endovascular treatment were dependent or dead at 1 year compared with 243 of 793 (30.6%) allocated neurosurgical treatment (p=0.0019). The relative and absolute risk reductions in dependency or death after allocation to an endovascular versus neurosurgical treatment were 22.6% (95% CI 8.9-34.2) and 6.9% (2.5-11.3), respectively. The risk of rebleeding from the ruptured aneurysm after 1 year was two per 1276 and zero per 1081 patient-years for patients allocated endovascular and neurosurgical treatment, respectively. In patients with a ruptured intracranial aneurysm, for which endovascular coiling and neurosurgical clipping are therapeutic options, the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. The data available to date suggest that the long-term risks of further bleeding from the treated aneurysm are low with either therapy, although somewhat more frequent with endovascular coiling.
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            Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms.

            Raphaël Blanc, Jacques Moret, Eric P. Schmidt … (2009)
            Stent-assisted coiling has expanded the treatment of intracranial aneurysms, but the rates of procedure-related neurological complications and the incidence of angiographic aneurysm recurrence of this novel treatment are not yet well known. We present our experience with stent-assisted coiling with special emphasis on procedure-related neurological complications and incidence of angiographic recurrence. Clinical and angiographic outcomes of 1137 consecutive patients (1325 aneurysms) coiled with and without stent-assisted coiling technique from January 2002 to January 2009 were retrospectively analyzed. There were 1109 aneurysms (83.5%) treated without and 216 (16.5%) treated with stents (15 of 216; 6.9% balloon-expandable versus 201 of 216; 93.1% self-expandable stents). Stents were delivered after coiling in 55.1% (119 of 216) and before coiling in 44.9% (97 of 216) of the cases. Permanent neurological procedure-related complications occurred in 7.4% (16 of 216) of the procedures with stents versus 3.8% (42 of 1109) in the procedures without stents (logistic regression P=0.644; OR: 1.289; 95% CI: 0.439 to 3.779). Procedure-induced mortality occurred in 4.6% (10 of 216) of the procedures with stents versus 1.2% (13 of 1109) in the procedures without stents (logistic regression P=0.006; OR: 0.116; 95% CI: 0.025 to 0.531). A total of 52.7% (114 of 216) of aneurysms treated with stents have been followed so far versus 69.8% (774 of 1109) of aneurysms treated without stents, disclosing angiographic recurrence in 14.9% (17 of 114) versus 33.5% (259 of 774), respectively (Fisher exact test P<0.0001; OR: 0.3485; 95% CI: 0.2038 to 0.5960). Stents were associated with a significant decrease of angiographic recurrences, but they were associated with more lethal complications compared with coiling without stents.
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              Better outcomes with treatment by coiling relative to clipping of unruptured intracranial aneurysms in the United States, 2001-2008.

              W Brinjikji, A.A Rabinstein, D.M. Nasr … (2011)
              Endovascular therapy has increasingly become an acceptable option for treatment of unruptured aneurysms. To better understand the recent trends in the use of and outcomes related to coiling compared with clipping for unruptured aneurysms in the United States, we evaluated the NIS. Hospitalizations for clipping or coiling of unruptured cerebral aneurysms from 2001 to 2008 were identified by cross-matching ICD codes for the diagnosis of unruptured aneurysm (437.3) with procedural codes for clipping (39.51) or coiling (39.52, 39.79, or 39.72) of cerebral aneurysms and excluding all patients with a diagnosis of subarachnoid hemorrhage (430) and intracerebral hemorrhage (431). Mortality and discharge to a long-term facility were evaluated for both clipping and coiling patient populations. The fraction of unruptured aneurysms treated with coiling increased from 20% in 2001 to 63% in 2008. For surgical clipping, the percentage of patients discharged to long-term facilities was 14.0% (4184/29,918) compared with 4.9% (1655/34,125) of coiled patients (P < .0001). Clipped patients also had a higher mortality rate because 344 (1.2%) clipped patients died compared with 215 (0.6%) coiled patients (P < .0001). Between 2001 and 2008, the overall number of adverse outcomes from treatment had decreased from 14.8% to 7.6%. The use of endovascular coiling relative to surgical clipping of unruptured intracranial aneurysms is associated with decreasing periprocedural morbidity and mortality among patients treated in the United States from 2001 to 2008.
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                Author and article information

                Contributors
                Tomasz Tykocki: ttomasz@mp.pl
                Journal
                Journal ID (nlm-ta): Acta Neurochir (Wien)
                Journal ID (iso-abbrev): Acta Neurochir (Wien)
                Title: Acta Neurochirurgica
                Publisher: Springer Vienna (Vienna )
                ISSN (Print): 0001-6268
                ISSN (Electronic): 0942-0940
                Publication date (Electronic): 6 February 2014
                Publication date PMC-release: 6 February 2014
                Publication date (Print): 2014
                Volume: 156
                Pages: 861-868
                Affiliations
                [ ]Department of Neurosurgery, Institute of Psychiatry and Neurology, Sobieskiego Street No 9, Warsaw, 02-957 Poland
                [ ]Department of Neurosurgery, Central Clinical Hospital Ministry of Interior in Warsaw, Warsaw, Poland
                [ ]Department of Neurosurgery, Wroclaw Medical University, Wroclaw, Poland
                Article
                Publisher ID: 2006
                DOI: 10.1007/s00701-014-2006-z
                PMC ID: 3988525
                PubMed ID: 24499992
                SO-VID: 8abffd5f-96c9-4fc4-bea3-e2abb97ed296
                Copyright © © The Author(s) 2014
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

                History
                Date received : 23 October 2013
                Date accepted : 18 January 2014
                Categories
                Subject: Clinical Article - Vascular
                Custom metadata
                issue-copyright-statement © Springer-Verlag Wien 2014

                ScienceOpen disciplines: Surgery
                Keywords: intracranial aneurysms,clipping,endovascular treatment,trends
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: intracranial aneurysms, clipping, endovascular treatment, trends

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