The Impact of Surgical Experience on Major Intraoperative Aneurysm Rupture and Their Consequences on Outcome: A Multivariate Analysis of 538 Microsurgical Clipping Cases

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Abstract

The incidence and associated mortality of major intraoperative rupture (MIOR) in intracranial aneurysm surgery is diverse. One possible reason is that many studies failed to consider and properly adjust the factor of surgical experience in the context. We conducted this study to clarify the role of surgical experience on MIOR and associated outcome. 538 consecutive intracranial aneurysm surgeries performed on 501 patients were enrolled in this study. Various potential predictors of MIOR were evaluated with stratified analysis and multivariate logistic regression. The impact of surgical experience and MIOR on outcome was further studied in a logistic regression model with adjustment of each other. The outcome was evaluated using the Glasgow Outcome Scale one year after the surgery. Surgical experience and preoperative Glasgow Coma Scale (GCS) were identified as independent predictors of MIOR. Experienced neurovascular surgeons encountered fewer cases of MIOR compared to novice neurosurgeons (MIOR, 18/225, 8.0% vs. 50/313, 16.0%, P = 0.009). Inexperience and MIOR were both associated with a worse outcome. Compared to experienced neurovascular surgeons, inexperienced neurosurgeons had a 1.90-fold risk of poor outcome. On the other hand, MIOR resulted in a 3.21-fold risk of unfavorable outcome compared to those without it. Those MIOR cases managed by experienced neurovascular surgeons had a better prognosis compared with those managed by inexperienced neurosurgeons (poor outcome, 4/18, 22% vs. 30/50, 60%, P = 0.013).

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Most cited references 27

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Microvascular decompression surgery in the United States, 1996 to 2000: mortality rates, morbidity rates, and the effects of hospital and surgeon volumes.

Steven N. Kalkanis, Emad N. Eskandar, Bob S. Carter … (2003)

Microvascular decompression (MVD) is associated with low mortality and morbidity rates at specialized centers, but many MVD procedures are performed outside such centers. We studied short-term end points after MVD in a national hospital discharge database sample. A retrospective cohort study was performed by using the Nationwide Inpatient Sample, 1996 to 2000. The sample included 1326 MVD procedures for treatment of trigeminal neuralgia, 237 for treatment of hemifacial spasm, and 27 for treatment of glossopharyngeal neuralgia, performed at 305 hospitals by 277 identified surgeons. The mortality rate was 0.3%, and the rate of discharge other than to home was 3.8%. Neurological complications were coded in 1.7% of cases, hematomas in 0.5%, and facial palsies in 0.6%, with 0.4% of patients requiring ventriculostomies and 0.7% postoperative ventilation. Trigeminal nerve section was also coded for 3.4% of patients with trigeminal neuralgia, more commonly among older patients (P = 0.08), among female patients (P = 0.03), and at teaching hospitals (P = 0.02). The median annual caseloads were 5 cases per hospital (range, 1-195 cases) and 3 cases per surgeon (range, 1-107 cases). With adjustment for age, sex, race, primary insurance, diagnosis (trigeminal neuralgia versus hemifacial spasm versus glossopharyngeal neuralgia), geographic region, admission type and source, and medical comorbidities, outcomes at discharge were superior at higher-volume hospitals (P = 0.006) and with higher-volume surgeons (P = 0.02). Complications were less frequent after surgery performed at high-volume hospitals (P = 0.04) or by high-volume surgeons (P = 0.01). The rate of discharge other than to home was 5.1% for the lowest-volume-quartile hospitals, compared with 1.6% for the highest-volume-quartile hospitals. Volume and mortality rate were not significantly related, but three of the four deaths in the series followed procedures performed by surgeons who had performed only one MVD procedure that year. Length of stay (median, 3 d) and hospital volume were not significantly related. Hospital charges were slightly higher at higher-volume hospitals (P = 0.007). Although most MVD procedures in the United States are performed at low-volume centers, mortality rates remain low. Morbidity rates are significantly lower at high-volume hospitals and with high-volume surgeons.

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Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: the CARAT study.

Lucas Elijovich, Steven Giannotta, Michael Lawton … (2008)

Intraprocedural rupture (IPR) is a well known complication of intracranial aneurysm treatment. Risks and predictors of IPR and its impact on outcome have not been clearly established. Potential predictors of IPR were evaluated in patients treated in the Cerebral Aneurysm Rerupture After Treatment (CARAT) study using multivariate logistic regression with stepwise elimination stratified by treatment modality. Periprocedural death or disability was defined as death or a change of >or=2 points on the Modified Rankin Scale at discharge compared to before treatment. IPR occurred in 14.6% of 1010 patients (299 coiled, 711 clipped): 19% with clipping and 5% with coiling (P<0.001). Among those clipped, 31% with IPR had periprocedural death or disability compared to 18% without IPR (P=0.001); among those coiled, 63% with IPR had periprocedural death or disability compared to 15% without IPR (P<0.001). Overall, coronary artery disease and initial lower Hunt and Hess Grade were independent predictors of IPR. For those undergoing coiling, independent predictors of IPR were Asian race, black race, COPD, and lower initial Hunt and Hess Grade. Among those undergoing clipping, hyperlipidemia and lower initial Hunt and Hess Grade were both independent predictors of IPR. IPR was common in patients undergoing treatment of ruptured aneurysms, particularly with surgical clipping. The frequency of IPR with new disability was similar in the surgical and endovascular treatment groups. Coronary artery disease, hyperlipidemia, race, COPD, and lower Hunt and Hess Grade were associated with greater risk of IPR, which may reflect differences in vessel fragility but requires further confirmation.

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Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states.

R G Dacey, David Tirschwell, Colin Derdeyn … (2003)

The goal of this study was to determine whether a hospital's volume of subarachnoid hemorrhage (SAH) cases affects mortality rates in patients with SAH. For certain serious illnesses and surgical procedures, outcome has been associated with hospital case volume. Subarachnoid hemorrhage, usually resulting from a ruptured cerebral aneurysm, yields a high mortality rate. There has been no multistate study of a diverse set of hospitals to determine whether in-hospital mortality rates are influenced by hospital volume of SAH cases. The authors conducted an analysis of a retrospective, administrative database of 16,399 hospitalizations for SAH (9290 admitted through emergency departments). These hospitalizations were from acute-care hospitals in 18 states representing 58% of the US population. Both univariate and multivariate analyses were used to assess the case volume-mortality rate relationship. The authors used patient age, sex, Medicaid status, hospital region, data source year, hospital case volume quartile, and a comorbidity index in multivariate generalized estimating equations to model the relationship between hospital volume and mortality rates after SAH. Patients with SAH who were treated in hospitals in which low volumes of patients with SAH are admitted through the emergency department had 1.4 times the odds of dying in the hospital (95% confidence interval 1.2-1.6) as patients admitted to high-volume hospitals after controlling for patient age, sex, Medicaid status, hospital region, database year, and comorbid conditions. Patients with a diagnosis of SAH on their discharge records who initially presented through the emergency department of a hospital with a high volume of SAH cases had significantly lower mortality rates. Concentrating care for this disease in high-volume SAH treatment centers may improve overall survival.

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Author and article information

Contributors

Nima Etminan: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 22 March 2016

Publication date Collection: 2016

Volume: 11

Issue: 3

Electronic Location Identifier: e0151805

Affiliations

[1 ]Department of Neurosurgery, Chang Gung Memorial Hospital-Linkou and Chang Gung University, Taoyuan, Taiwan

[2 ]Department of Neurosurgery, Chang Gung Memorial Hospital-Chiayi and Chang Gung Institute of Technology, Chiayi, Taiwan

[3 ]Department of Neurosurgery, Kaohsiung Medical University Hospital and Kaohsiung Medical University, Kaohsiung, Taiwan

[4 ]Division of Neurosurgery, Saint Paul's Hospital, Taoyuan, Taiwan

[5 ]Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan

Heinrich-Heine University, GERMANY

Author notes

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: CEH TKL. Performed the experiments: CEH TKL MHL STL CNC CLL YHH YCH TCH CJC. Analyzed the data: CEH TKL CJC. Contributed reagents/materials/analysis tools: TKL MHL STL CNC CLL YHH YCH TCH CJC. Wrote the paper: CEH TKL.

‡ These authors are co-first authors on this work.

* E-mail: tklin100@ 123456cgmh.org.tw

Article

Publisher ID: PONE-D-15-37265

DOI: 10.1371/journal.pone.0151805

PMC ID: 4803230

PubMed ID: 27003926

SO-VID: b661dbea-97a3-4fa5-bc1c-3609e7754b9c

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 30 August 2015

Date accepted : 5 March 2016

Page count

Figures: 2, Tables: 3, Pages: 10

Funding

The authors received no specific funding for this work. Nevertheless, Mr. Yu Jr Lin who assisted in the statistics of this work was supported by grants from Biostatistical Center for Clinical Research, Chang Gung Memorial Hospital (CLRPG3D0041).

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The Impact of Surgical Experience on Major Intraoperative Aneurysm Rupture and Their Consequences on Outcome: A Multivariate Analysis of 538 Microsurgical Clipping Cases

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Abstract

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Most cited references 27

Microvascular decompression surgery in the United States, 1996 to 2000: mortality rates, morbidity rates, and the effects of hospital and surgeon volumes.

Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: the CARAT study.

Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states.

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