Treatment of Ruptured and Unruptured Cerebral Aneurysms
Treatment of Ruptured and Unruptured Cerebral Aneurysms
From 1998 to 2007, 34 899 discharges associated with the treatment of a cerebral aneurysm were identified, including 20 134 ruptured and 14 765 unruptured aneurysms (Table 1). The mean age was 53.2 years. The majority of patients were Caucasian and women outnumbered men by at least twofold. Men and non-whites were more likely than women and whites to present as ruptured. Most treatments took place at large medical centers and those with teaching responsibilities. The South had the greatest number of treated patients and private insurance was the most commonly reported payment type.
The number of aneurysms treated yearly increased significantly during the study period, with treatment of unruptured aneurysms accounting for the majority of the increase (figure 1). For both ruptured and unruptured aneurysms, the trend was toward an increased use of coiling (figures 2A,B). This increase was particularly notable after 2002 when there was a twofold increase in the use of coiling for both aneurysm types. Before 2002, 90.7% of ruptured aneurysms were treated with clipping versus 57.1% after 2002 (OR=7.3; 95% CI 6.7 to 7.9). For unruptured aneurysms, 79.4% were treated with clipping before 2002 versus 38.3% after 2002 (OR=6.2; 95% CI 5.7 to 6.7) (figure 2C). The number of unruptured aneurysms treated with surgical clipping remained stable over time while the number of ruptured aneurysms that were surgically treated decreased.
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Figure 1.
The number of ruptured and unruptured cerebral aneurysms treated annually in the USA, 1998–2007. Although the yearly presentation of ruptured aneurysms was stable, the number of unruptured aneurysms treated in the USA increased significantly during this period.
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Figure 2.
Changes of treatment selection for ruptured and unruptured cerebral aneurysms in the USA before and after the publication of the International Subarachnoid Aneurysm Trial (2002). Increased use of coiling was found for both ruptured aneurysms (A) and unruptured cerebral aneurysms (B) from 1998 to 2007. There was a twofold increase in the use of coiling for both aneurysm types after 2002 (C).
We examined factors related to coiling use by rupture status. Across the decade, older age, white race, higher income level, public healthcare coverage, later year of presentation, Midwest location, hospital type (teaching), higher Charlson comorbidity score and non-emergency presentation were significantly associated with coiling for ruptured aneurysms (Table 2). In particular, Caucasians who presented with a ruptured aneurysm were more likely to be coiled than blacks (OR=1.30; 95% CI 1.13 to 1.48) and patients with public insurance were more likely to be coiled than those covered by private payers (OR=1.14; 95% CI 1.03 to 1.27). For unruptured aneurysms, similar parameters were identified during multivariable analyses except race and Charlson comorbidity score (Table 2). In addition, male patients with an unruptured aneurysm were more likely to be coiled than female subjects (OR=1.26; 95% CI 1.13 to 1.40).
We further investigated whether the above variables associated with coiling usage changed over the decade (Table 3). For ruptured aneurysms, the significance of a number of factors lessened over time; in particular, although men were more likely than women (OR=1.38; 95% CI 1.04 to 1.59) and whites more likely than blacks (OR=1.68; 95% CI 1.21 to 2.33) to be coiled before 2002, differences associated with sex (OR=1.05; 95% CI 0.94 to 1.17) and race (OR=1.23; 95% CI 1.06 to 1.43) had disappeared or reduced, respectively, after 2002. While large, teaching hospitals performed most of the coiling procedures for ruptured aneurysms before 2002, smaller non-teaching hospitals were equally as likely to perform these procedures after that year. Similar trends were found for unruptured aneurysms, although the tendency for coiling rates to become uniform was less prominent across patient and hospital demographic subgroups over time. For instance, after 2002 men remained more likely than women to be coiled (OR=1.27; 95% CI 1.12 to 1.43) and coiling was still more frequently performed in large (OR=2.14; 95% CI 1.72 to 2.67), teaching (OR=1.44; 95% CI 1.21 to 1.72) and mid-west (OR=1.44; 95% CI 1.20 to 1.74) hospitals, although the importance of these factors decreased compared with pre-2002 OR values (Table 3).
Overall, in-hospital mortality was 1.2% for patients with an unruptured aneurysm and 13.7% for patients with SAH. Regardless of rupture status and treatment choice, mortality for treated aneurysms nationwide decreased steadily over time (figure 3). Among patients with ruptured aneurysms, increased mortality was associated with female sex, non-private insurance, higher Charlson comorbidity score, coiling usage and non-teaching hospitals. For unruptured aneurysms, non-elective admission and clipping were associated with a higher mortality (Table 4).
(Enlarge Image)
Figure 3.
Changes of in-hospital mortality for treated ruptured and unruptured cerebral aneurysms in the USA from 1998 to 2007. Regardless of ruptured status and treatment choice, mortality nationwide decreased steadily over time.
Results
From 1998 to 2007, 34 899 discharges associated with the treatment of a cerebral aneurysm were identified, including 20 134 ruptured and 14 765 unruptured aneurysms (Table 1). The mean age was 53.2 years. The majority of patients were Caucasian and women outnumbered men by at least twofold. Men and non-whites were more likely than women and whites to present as ruptured. Most treatments took place at large medical centers and those with teaching responsibilities. The South had the greatest number of treated patients and private insurance was the most commonly reported payment type.
The number of aneurysms treated yearly increased significantly during the study period, with treatment of unruptured aneurysms accounting for the majority of the increase (figure 1). For both ruptured and unruptured aneurysms, the trend was toward an increased use of coiling (figures 2A,B). This increase was particularly notable after 2002 when there was a twofold increase in the use of coiling for both aneurysm types. Before 2002, 90.7% of ruptured aneurysms were treated with clipping versus 57.1% after 2002 (OR=7.3; 95% CI 6.7 to 7.9). For unruptured aneurysms, 79.4% were treated with clipping before 2002 versus 38.3% after 2002 (OR=6.2; 95% CI 5.7 to 6.7) (figure 2C). The number of unruptured aneurysms treated with surgical clipping remained stable over time while the number of ruptured aneurysms that were surgically treated decreased.
(Enlarge Image)
Figure 1.
The number of ruptured and unruptured cerebral aneurysms treated annually in the USA, 1998–2007. Although the yearly presentation of ruptured aneurysms was stable, the number of unruptured aneurysms treated in the USA increased significantly during this period.
(Enlarge Image)
Figure 2.
Changes of treatment selection for ruptured and unruptured cerebral aneurysms in the USA before and after the publication of the International Subarachnoid Aneurysm Trial (2002). Increased use of coiling was found for both ruptured aneurysms (A) and unruptured cerebral aneurysms (B) from 1998 to 2007. There was a twofold increase in the use of coiling for both aneurysm types after 2002 (C).
We examined factors related to coiling use by rupture status. Across the decade, older age, white race, higher income level, public healthcare coverage, later year of presentation, Midwest location, hospital type (teaching), higher Charlson comorbidity score and non-emergency presentation were significantly associated with coiling for ruptured aneurysms (Table 2). In particular, Caucasians who presented with a ruptured aneurysm were more likely to be coiled than blacks (OR=1.30; 95% CI 1.13 to 1.48) and patients with public insurance were more likely to be coiled than those covered by private payers (OR=1.14; 95% CI 1.03 to 1.27). For unruptured aneurysms, similar parameters were identified during multivariable analyses except race and Charlson comorbidity score (Table 2). In addition, male patients with an unruptured aneurysm were more likely to be coiled than female subjects (OR=1.26; 95% CI 1.13 to 1.40).
We further investigated whether the above variables associated with coiling usage changed over the decade (Table 3). For ruptured aneurysms, the significance of a number of factors lessened over time; in particular, although men were more likely than women (OR=1.38; 95% CI 1.04 to 1.59) and whites more likely than blacks (OR=1.68; 95% CI 1.21 to 2.33) to be coiled before 2002, differences associated with sex (OR=1.05; 95% CI 0.94 to 1.17) and race (OR=1.23; 95% CI 1.06 to 1.43) had disappeared or reduced, respectively, after 2002. While large, teaching hospitals performed most of the coiling procedures for ruptured aneurysms before 2002, smaller non-teaching hospitals were equally as likely to perform these procedures after that year. Similar trends were found for unruptured aneurysms, although the tendency for coiling rates to become uniform was less prominent across patient and hospital demographic subgroups over time. For instance, after 2002 men remained more likely than women to be coiled (OR=1.27; 95% CI 1.12 to 1.43) and coiling was still more frequently performed in large (OR=2.14; 95% CI 1.72 to 2.67), teaching (OR=1.44; 95% CI 1.21 to 1.72) and mid-west (OR=1.44; 95% CI 1.20 to 1.74) hospitals, although the importance of these factors decreased compared with pre-2002 OR values (Table 3).
Overall, in-hospital mortality was 1.2% for patients with an unruptured aneurysm and 13.7% for patients with SAH. Regardless of rupture status and treatment choice, mortality for treated aneurysms nationwide decreased steadily over time (figure 3). Among patients with ruptured aneurysms, increased mortality was associated with female sex, non-private insurance, higher Charlson comorbidity score, coiling usage and non-teaching hospitals. For unruptured aneurysms, non-elective admission and clipping were associated with a higher mortality (Table 4).
(Enlarge Image)
Figure 3.
Changes of in-hospital mortality for treated ruptured and unruptured cerebral aneurysms in the USA from 1998 to 2007. Regardless of ruptured status and treatment choice, mortality nationwide decreased steadily over time.
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