Departments of1Neurological Surgery and.
2Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
J Neurosurg. 2020 Feb 7;134(3):848-861. doi: 10.3171/2019.12.JNS192755. Print 2021 Mar 1.
Adoption of endovascular treatment (EVT) and other advances in aneurysm care have shifted practice patterns of cerebral aneurysm treatment over the past 2 decades in the US. The objective of this study was to determine whether resulting trends in volumes, outcomes, and complications have matured in general practice or continue to evolve.
Data were obtained from the National Inpatient Sample from 1993 to 2015. ICD-9 codes were used to estimate annual volumes, outcomes, and complications following treatment of ruptured and unruptured aneurysms. Univariate and multivariate analyses were used to estimate risk ratios for complications and outcomes. Trends in time were assessed utilizing annual percentage change (APC).
The authors found a nearly 5-fold increase in annual admissions with diagnoses of unruptured aneurysms, whereas SAH volume increased less than 50%. Clipping ruptured aneurysms steadily declined (APC -0.86%, p = 0.69 until 1999, then -6.22%, p < 0.001 thereafter), whereas clipping unruptured aneurysms slightly increased (APC 2.02%, p < 0.001). EVT tripled in 2002-2004 and steadily increased thereafter (APC 7.22%, p < 0.001 and 5.85%, p = 0.01 for unruptured and ruptured aneurysms, respectively). Despite a 3-fold increase in both diagnosis and treatment of unruptured aneurysms, the incidence of SAH remained steady at 12 per 100,000 persons per year (APC 0.04%, p = 0.83). In contrast, SAH severity increased over time, as did patient age and comorbidities (all p < 0.001). SAH led to nonroutine discharge more frequently over time after both EVT and clipping (APC 1.24% and 1.10%, respectively), although mortality decreased during the same time (APC -2.48% and -1.44%, respectively). Complications were more frequent after clipping than EVT, but this differential risk diminished during the study period and was less perceptible in ruptured aneurysms. The proportion of patients discharged home after treatment of unruptured aneurysms was significantly lower (p < 0.001) after clipping (69.3%-79.5%) than EVT (88.3%-93.3%); both proportions changed minimally since 1998 (APC -0.39%, p = 0.02, and APC -0.11%, p = 0.14, respectively).
EVT volume markedly increased for ruptured and unruptured aneurysms from 1993 to 2015, whereas clipping decreased for ruptured and slightly increased for unruptured aneurysms. The incidence of SAH remained unchanged despite increased diagnosis and treatment of unruptured aneurysms. In ruptured aneurysms, SAH severity has increased over time, as have age, comorbidities, and nonroutine discharges. In contrast, routine discharge after treatment of unruptured aneurysms remains largely unchanged since 1998 and remains lower with clipping.
在美国，血管内治疗（EVT）和其他动脉瘤治疗领域的进展改变了过去 20 年来脑动脉瘤治疗的实践模式。本研究的目的是确定总体实践中体积、结果和并发症的趋势是否已经成熟，或者是否仍在发展。
从 1993 年至 2015 年，从国家住院患者样本中获取数据。使用 ICD-9 代码来估计治疗破裂和未破裂动脉瘤后的年度体积、结果和并发症。使用单变量和多变量分析来估计并发症和结果的风险比。利用年度百分比变化（APC）评估时间趋势。
作者发现，未破裂动脉瘤的年度入院诊断数增加了近 5 倍，而蛛网膜下腔出血（SAH）的数量增加不到 50%。夹闭破裂动脉瘤的数量稳步下降（APC-0.86%，p=0.69，直到 1999 年，然后下降 6.22%，p<0.001），而夹闭未破裂动脉瘤的数量略有增加（APC 2.02%，p<0.001）。EVT 在 2002-2004 年翻了三倍，此后稳步增加（APC 7.22%，p<0.001和 5.85%，p=0.01，分别为未破裂和破裂动脉瘤）。尽管未破裂和破裂动脉瘤的诊断和治疗都增加了三倍，但蛛网膜下腔出血的发生率仍保持在每年每 10 万人 12 例（APC 0.04%，p=0.83）。相比之下，蛛网膜下腔出血的严重程度随着时间的推移而增加，患者年龄和合并症也随之增加（均 p<0.001）。尽管在此期间死亡率下降（APC-2.48%和-1.44%，分别），但 EVT 和夹闭后蛛网膜下腔出血导致非常规出院的频率也随着时间的推移而增加（APC 1.24%和 1.10%，分别）。夹闭后的并发症比 EVT 更常见，但这种差异风险在研究期间减小，在破裂动脉瘤中不太明显。自 1998 年以来，夹闭治疗未破裂动脉瘤后患者出院回家的比例（p<0.001）明显低于 EVT（69.3%-79.5%比 88.3%-93.3%）；这两个比例自 1998 年以来变化不大（APC-0.39%，p=0.02 和 APC-0.11%，p=0.14）。
从 1993 年到 2015 年，EVT 的破裂和未破裂动脉瘤的体积显著增加，而夹闭的破裂动脉瘤数量减少，未破裂动脉瘤的数量略有增加。尽管未破裂动脉瘤的诊断和治疗有所增加，但蛛网膜下腔出血的发生率仍保持不变。在破裂动脉瘤中，蛛网膜下腔出血的严重程度随着时间的推移而增加，患者年龄、合并症和非常规出院的情况也有所增加。相比之下，自 1998 年以来，未破裂动脉瘤治疗后的常规出院率基本保持不变，夹闭后出院率仍然较低。
