465. Treatment of Cerebral Aneurysms in the Post-ISAT Era: Trends and Outcomes
Features NREF-funded Author
Authors: David J McCarthy; Evan Luther, MD; Stephanie Chen, MD; Samir Sur, MD; Marie- Christine Brunet, MD; Dallas Sheinberg, BS; Dileep Yavagal, MD; Eric Peterson, MD; Robert Starke, MD, MSc (miami, FL)
Following the ISUIA and ISAT studies, the paradigm for treatment of cerebral aneurysms shifted from open surgical clipping to endovascular embolization as primary therapy in many cases. While this trend has been widely acknowledged, outcome data and large-scale treatment patterns have not been reported in recent years.
The National Inpatient Sample from 2004-2014 was reviewed. Aneurysmal Subarachnoid hemorrhage (aSAH) and unruptured aneurysm (UA) discharges were identified along with treatment given, surgical clipping or endovascular repair. Time trend plots were created. Following Shapiro-Wilks normality confirmation, linear and logistic regression estimated significant yearly changes in treatments. P≤0.05 considered significant (SAS 9.4).
A total of 397,540 SAH and 387,353 UA discharges were reviewed. There was a significant yearly increase in SAH (+732, p=0.014) and UA (+2550, p<0.0001) discharges (2004 vs. 2014; SAH 33423 vs 40000; unruptured 21711 vs 44575). For aSAH treatment, yearly discharges after clipping decreased (-287, p=0.0001) and increased for endovascular treatment (+366, p=0.0005) (2004 vs. 2014; aSAH-clipping 6854 vs 3435; aSAH-endovascular 4083 vs 7740). For treated UA, yearly discharges for clipping remained stable and increased for endovascular therapy (+615, p<0.0001) (2004 vs. 2014; UA-clipping 3672 vs 3745; UA-endovascular 4083 vs 9705). Over time, inpatient mortality decreased for both clipped (p<0.0001) and endovascularly treated (p<0.0001) aSAH (2004 vs. 2014 mortality rates; aSAH-clipped 13% vs 11.7%; SAH-endovascular 15.8% vs. 12.7%). Mortality rates for clipped UA decreased over time (p<0.0001) and did not change for endovascular treated UA (2004 vs. 2014 mortality rates; UA-clipped 1.57% vs 0.40%; UA-endovascular 0.59% vs. 0.52%). Length of stay decreased for UA and not ruptured anuerysms.
Patients with ruptured and unruptured aneurysms are increasingly treated with endovascular therapy over clipping. Mortality rates of ruptured aneurysms is improving regardless of treatment; whereas, mortality in unruptured aneurysms is only improving for surgical clipping.