Feng Austin Y, Sussman Eric S, Jin Michael C, Wong Sandy, Lopez Jaime, Pulli Benjamin, Heit Jeremy J, Telischak Nicholas
Neurosurgery, Stanford University School of Medicine, Stanford, USA.
Neurology, Stanford University School of Medicine, Stanford, USA.
Cureus. 2021 Jan 27;13(1):e12946. doi: 10.7759/cureus.12946.
Introduction The treatment of cerebral arteriovenous malformations (AVMs) may result in neurologic morbidity, particularly when an AVM is located in or adjacent to eloquent brain regions. Intraoperative neurophysiologic monitoring (IONM) may be utilized to reduce the risk of iatrogenic injury during endovascular AVM embolization; however, IONM for endovascular AVM embolization is not ubiquitously the standard of care. Methods Admissions for AVM embolization were assessed from the IBM MarketScan® Commercial and Medicare Supplemental databases (IBM Watson Health, Somers, NY). Inclusion criterion for patients was continuous enrollment six months before and after the index encounter. The use of IONM and presence of intracranial hemorrhage (ICH) were noted. Propensity-score matched cohorts with and without IONM were generated to minimize bias between treatment groups (adjusting for age, sex, and comorbidities). Results From 2007 to 2016, there were 16,279 patients diagnosed with cerebral AVM in the MarketScan database. Embolized patients were stratified into IONM and non-IONM cohorts; there were 357 patients in the IONM cohort and 1775 patients in the non-IONM cohort. Provider types were significantly different between cohorts (p<0.005). Unruptured AVMs were significantly more likely to be embolized with adjunctive IONM (17.7%) compared to ruptured AVMs (7.9%) (p<0.005). After balancing for baseline comorbidities, there were 266 patients in the IONM cohort, and 1347 patients in the non-IONM cohort. Among unruptured AVM patients, IONM was linked to a significantly shorter length of stay (2.72 versus 4.92 days; p<0.005), significantly lower rates of complications within 30 days of discharge (0.00% versus 1.88%; p=0.038), and significantly lower total payment ($40,179 versus $50,844; p<0.0001). Conclusion Endovascular embolization for unruptured AVMs performed with adjunctive IONM was associated with shorter length of stay, lower complication rates, and hospitalization costs.
引言 脑动静脉畸形（AVM）的治疗可能会导致神经功能障碍，尤其是当AVM位于明确的脑区或其附近时。术中神经生理监测（IONM）可用于降低血管内AVM栓塞过程中发生医源性损伤的风险；然而，血管内AVM栓塞的IONM并非普遍的标准治疗方法。方法 从IBM MarketScan®商业和医疗保险补充数据库（IBM Watson Health，纽约州萨默斯）评估AVM栓塞的入院情况。患者的纳入标准是在索引事件前后连续登记六个月。记录IONM的使用情况和颅内出血（ICH）的存在情况。生成了有IONM和无IONM的倾向评分匹配队列，以尽量减少治疗组之间的偏差（根据年龄、性别和合并症进行调整）。结果 2007年至2016年，MarketScan数据库中有16279例患者被诊断为脑AVM。栓塞患者被分为IONM组和非IONM组；IONM组有357例患者，非IONM组有1775例患者。队列之间的医疗服务提供者类型有显著差异（p<0.005）。与破裂的AVM（7.9%）相比，未破裂的AVM更有可能在辅助IONM下进行栓塞（17.7%）（p<0.005）。在平衡基线合并症后，IONM组有266例患者，非IONM组有1347例患者。在未破裂的AVM患者中，IONM与显著缩短的住院时间（2.72天对4.92天；p<0.005）、出院后30天内显著较低的并发症发生率（0.00%对1.88%；p=0.038）以及显著较低的总费用（40179美元对50844美元；p<0.0001）相关。结论 采用辅助IONM对未破裂的AVM进行血管内栓塞与缩短住院时间、降低并发症发生率和住院费用相关。
