Thromboembolic Events With the Woven Endobridge Device: Incidence, Predictive Factors, and Management.

BACKGROUND AND OBJECTIVES: The Woven EndoBridge (WEB) device has been increasingly used to treat wide-neck aneurysms showing a safe and effective profile, but a relatively high number of thromboembolic events (TEEs) have been reported with such treatment. We aimed to evaluate the incidence and management of TEEs and possible predictive factors related to WEB embolization of ruptured and unruptured intracranial aneurysms. METHODS: A single-center database with consecutive aneurysms treated with a WEB device between July 2012 and May 2022 was reviewed for intraoperative and delayed TEEs. Univariate and multivariable analyses were used to determine factors associated with TEEs. RESULTS: A total of 266 independent aneurysms were treated with WEB devices in 245 patients (mean age 55.78 ± 11.64 years, 169 (63.5%) females, 80 (30%) ruptured). The overall rate of TEEs is 13% (35/266), including 8.7% intraoperative. Symptomatic TEEs with clinical sequelae at a 3-month follow-up are reported to be 2.6% (7/266) with no TEE-related mortality. Both the replacement of a WEB device during the procedure (adjusted odds ratio = 2.61, 95% CI 1.24-5.49; P = .01) and ruptured aneurysms (adjusted odds ratio = 2.74, 95% CI 1.31-5.7; P = .007) were independent predictors of TEEs. A case-by-case management of intraprocedural TEE is also presented; tirofiban was successfully used in most cases of this cohort. CONCLUSION: In this study, we demonstrated that ruptured aneurysms and WEB device replacement during the procedure were independent predictive factors for TEEs. As a result, making the correct choice of WEB is crucial for improving treatment outcomes. Moreover, with proper medical management of TEEs, minimal morbidity and no mortality could be achieved, which reinforces the safety of the technique.

Intraluminal assessment of inflammatory factors in patients with intracranial aneurysms.

BACKGROUND: The formation, growth, and rupture of intracranial aneurysms (IA) are due to several pathophysiological mechanisms, including focal hemodynamic injury and inflammation of the arterial wall. We investigated the differences between venous, parent artery, and intra-aneurysmal blood by measuring inflammatory factors and antibodies in patients with ruptured (rIA) or unruptured intracranial aneurysms (uIA). METHOD: A prospective study was performed in patients who presented with IA and required endovascular treatment. Blood was drawn from the lumen of the aneurysm sac, the parent artery, and the peripheral veins, to determine the serum concentrations of complement factors C3, C4, IgG, IgM, IgA antibodies, and C-reactive protein (CRP). RESULTS: Thirty-six patients (15 with uIA and 21 with rIA) were enrolled in the study. In both groups, C3, C4, IgM, IgG, and IgA showed a gradual decrease from venous to intra-aneurysmal samples, but only IgG in the parent artery and intra-aneurysmal samples reached a significant decrease in uIA compared with venous samples. Accordingly, C3 and IgG concentrations in the intra-aneurysmal samples showed a significant decrease in rIA compared with venous samples. A significant increase in CRP concentrations was observed in parent artery and intra-aneurysmal samples from patients with rIA compared with patients with uIA; a significant increase in C3 concentrations was observed in parent artery samples from patients with rIA compared with patients with uIA, and a significant decrease in IgM concentrations was observed in venous, parent artery, and intra-aneurysmal samples from patients with rIA compared with patients with uIA. CONCLUSIONS: A decrease in C3 and IgG in the aneurysm sac indicates activation of the complement system in the arterial wall. CRP in the aneurysm sac and lumen of the parent artery was significantly increased in ruptured compared with unruptured aneurysms, whereas venous, parent artery, and intra-aneurysmal IgM were decreased in ruptured compared with unruptured aneurysms. These results argue for the role of an ongoing inflammatory process in aneurysms leading to their growth and rupture.

Predicting the formation of mixed pattern hemorrhages in ruptured middle cerebral artery aneurysms based on a decision tree model: A multicenter study.

OBJECTIVE: Mixed-pattern hemorrhages (MPH) commonly occur in ruptured middle cerebral artery (MCA) aneurysms and are associated with poor clinical outcomes. This study aimed to predict the formation of MPH in a multicenter database of MCA aneurysms using a decision tree model. METHODS: We retrospectively reviewed patients with ruptured MCA aneurysms between January 2009 and June 2020. The MPH was defined as subarachnoid hemorrhages with intracranial hematomas and/or intraventricular hemorrhages and/or subdural hematomas. Univariate and multivariate logistic regression analyses were used to explore the prediction factors of the formation of MPH. Based on these prediction factors, a decision tree model was developed to predict the formation of MPH. Additional independent datasets were used for external validation. RESULTS: We enrolled 436 patients with ruptured MCA aneurysms detected by computed tomography angiography; 285 patients had MPH (65.4%). A multivariate logistic regression analysis showed that age, aneurysm size, multiple aneurysms, and the presence of a daughter dome were the independent prediction factors of the formation of MPH. The areas under receiver operating characteristic curves of the decision tree model in the training, internal, and external validation cohorts were 0.951, 0.927, and 0.901, respectively. CONCLUSION: Age, aneurysm size, the presence of a daughter dome, and multiple aneurysms were the independent prediction factors of the formation of MPH. The decision tree model is a useful visual triage tool to predict the formation of MPH that could facilitate the management of unruptured aneurysms in routine clinical work.

An Analysis of the Incidence and Cost of Intracranial Aneurysm and Subarachnoid Haemorrhage Treatment between 2013 and 2021.

The incidence of unruptured intracranial aneurysms (UIAs) amounts to 3.2% among adults. The annual risk of aneurysm rupture is 2-10% and it results in subarachnoid haemorrhage (SAH). The aim of this study is to assess changes in the incidence of unruptured intracranial aneurysms and subarachnoid haemorrhages in Poland between 2013 and 2021 and the cost associated with their in-hospital treatment in the acute phase. The analysis was based on the National Health Fund database. Patients diagnosed with UIA and SAH and hospitalised between 2013 and 2021 were chosen. The statistical analysis was performed with an assumed significance level of α = 0.05. The ratio between the prevalence of SAH and UIA diagnoses was 4:6. The proportion of women in relation to men was higher in both diagnoses. The highest proportions of patients with diagnoses SAH and UIA were found in highly urbanised provinces. The value of medical services in 2021 compared to 2013 increased by 81.8%. The highest values in this period were recorded in Mazowieckie province, and the lowest were recorded in Opolskie province. The overall number of patients hospitalised with diagnosis of UIA or SAH did not decrease, but the risk of aneurysm rupture probably decreased, which resulted in lower incidence of SAH in subsequent years of observation. The recorded changes in the dynamics of the value of medical services per patient or per hospitalisation largely coincided. However, it is difficult to speculate on expected value levels as not all provinces showed linear changes in the value of services provided.

Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis.

BACKGROUND: In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE: To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center. METHODS: All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. RESULTS: Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance. CONCLUSION: Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.

Comparison between rupture/growth risk scores and treatment recommendation scores application to aneurysmal subarachnoid hemorrhage patients: A multicenter cross-reliability assessment study.

BACKGROUND: Two score families were introduced to help clinicians about the decision-making regarding intracranial aneurysms management. The first family estimates the growth/rupture risk (GRS), whereas the second provides straightforward recommendation (RS) for treatment decisions. However, both remain poorly validated and little is known about their agreement. In this paper, we performed a retrospective concordance analysis among the two scores families through their application to a multicenter cohort of SAH patients. METHODS: Demographical, clinical and radiological data were extracted in conformance with the variables included in PHASES, UCAS, ELAPSS, Juvela's growth score (JGS), UIATS and Juvela's treatment score (JTS). Individual patients' score were calculated for both score families, and pooled data were then analyzed. RESULTS: Overall, 146 patients were included. True positive rates were: 51.4% for PHASES; 71.9% for UCAS; between 60.3% and 90.4% for JTS; and between 27.4% and 68.5% for UIATS. In patients showing UIATS unclear recommendation and low JTS score (RS), UCAS outperformed PHASES (GRS) in identifying aneurysms at higher risk of rupture. Same results we found for patients with conservative UIATS recommendation and very low JTS score. Forty-to-sixty percent of aneurysms with unclear or conservative RS recommendation would have been identified as at high risk with GRS. CONCLUSIONS: Retrospectively applied, JTS appeared outperforming UIATS in correctly recommending treatment in a higher percentage of patients. UIATS and JTS appeared agreeing more with UCAS than PHASES predictions. Around 50% of patients with unclear or conservative UIATS/JTS recommendations were been classified as at higher growth risk by ELAPSS and JGS.

Association of Aortic Aneurysms and Dissections With Subarachnoid Hemorrhage.

Background It is uncertain whether aortic diseases, such as aneurysm and dissection, are associated with intracranial aneurysm formation and aneurysmal subarachnoid hemorrhage (SAH). Methods and Results We used data on claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. Our exposure variable was hospitalization with an unruptured or ruptured aortic aneurysm or aortic dissection. The outcome was nontraumatic SAH. Variables were ascertained by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), diagnosis codes. Survival statistics were used to calculate incidence rates. Cox proportional hazards analysis was used to examine the association between aortic aneurysm/dissection and SAH while adjusting for demographics, vascular risk factors, and Charlson comorbidities. Among 1 781 917 beneficiaries, 32 551 (1.8%) had a documented aortic aneurysm or dissection. During 4.6±2.2 years of follow-up, 2538 patients (0.14%) developed a nontraumatic SAH. The incidence of SAH was 9 (95% CI, 7-11) per 10 000 patients per year in those with aortic aneurysm/dissection compared with 3 (95% CI, 3-3) per 10 000 patients per year in those without aortic aneurysm/dissection. After adjustment for demographics, stroke risk factors, and Charlson comorbidities, patients with aortic aneurysm/dissection faced an increased risk of SAH (hazard ratio, 1.4; 95% CI, 1.02-1.9; P=0.04). Conclusions In a nationally representative sample of Medicare beneficiaries, aortic aneurysm/dissection was associated with an increased risk of nontraumatic SAH.

Cognitive Sequelae of Unruptured and Ruptured Intracranial Aneurysms and their Treatment: Modalities for Neuropsychological Assessment.

BACKGROUND: Cognitive sequelae frequently follow subarachnoid hemorrhage (SAH) and include deficits across multiple domains of executive function. This factor affects overall functional outcomes negatively, especially in younger patients. Several clinical correlates predict development and severity of cognitive dysfunction after SAH. Hypothetical mechanisms of cognitive dysfunction in the absence of radiographic lesion include cerebral hypoperfusion and blood breakdown products, resulting in perturbed interneuronal communication and network synchrony, excitotoxicity, and altered microRNA expression. METHODS: The PubMed database was searched for articles discussing cognitive outcomes in patients with unruptured and ruptured intracranial aneurysmal disease, sequelae of treatment, and modalities for neuropsychologic testing. RESULTS: Treatment of unruptured intracranial aneurysms, although capable of preventing SAH, comes with its own set of complications and may also affect cognitive function. Neuropsychological tests such as the Montreal Cognitive Assessment, Mini-Mental Status Examination, and others have proved useful in evaluating cognitive decline. Studies using functional neurologic imaging modalities have identified regions with altered activation patterns during various cognitive tasks. The sum of research efforts in this field has provided useful insights and an initial understanding of cognitive dysfunction after aneurysm treatment and SAH that should prove useful in guiding and rendering future investigations more fruitful. CONCLUSIONS: Development of finer and more sensitive neuropsychological tests in evaluating the different domains of cognitive function after aneurysm treatment and SAH in general will be useful in accurately determining outcomes after ictus and comparing efficacy of different therapeutic strategies.

Readmission After Aneurysmal Subarachnoid Hemorrhage: A Nationwide Readmission Database Analysis.

BACKGROUND AND PURPOSE: The goal of this nationwide study is to evaluate the suitability of readmission as a quality indicator in the aneurysmal subarachnoid hemorrhage (SAH) population. METHODS: Patients with aneurysmal SAH were extracted from the Nationwide Readmission Database (2013). Multivariable Cox proportional hazard regression was used to evaluate predictors of a 30-day readmission, and multivariable linear regression was used to analyze the association of hospital readmission rates with hospital mortality rates. Predictors screened included patient demographics, comorbidities, severity of SAH, complications from the SAH hospitalization, and hospital characteristics. RESULTS: The 30-day readmission rate was 10.2% (n=346) among the 3387 patients evaluated, and the most common reasons for readmission were neurological, hydrocephalus, infectious, and venous thromboembolic complications. Greater number of comorbidities, increased severity of SAH, and discharge disposition other than to home were independent predictors of readmission (P≤0.03). Although hydrocephalus during the SAH hospitalization was associated with readmission for the same diagnosis, other readmissions were not associated with having sustained the same complication during the SAH hospitalization. Hospital mortality rate was inversely associated with hospital SAH volume (P=0.03) but not significantly associated with hospital readmission rate; hospital SAH volume was also not associated with SAH readmissions. CONCLUSIONS: In this national analysis, readmission was primarily attributable to new medical complications in patients with greater comorbidities and severity of SAH rather than exacerbation of complications from the SAH hospitalization. Additionally, hospital readmission rates did not correlate with other established quality metrics. Therefore, readmission may be a suboptimal quality indicator in the SAH population.

Pipeline embolization device versus coiling for the treatment of large and giant unruptured intracranial aneurysms: a cost-effectiveness analysis.

OBJECTIVE Rupture of large or giant intracranial aneurysms leads to significant morbidity, mortality, and health care costs. Both coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for the treatment of unruptured large and giant intracranial aneurysms; however, the relative cost-to-outcome ratio is unknown. The authors present the first cost-effectiveness analysis to compare the economic impact of the PED compared with coiling or no treatment for the endovascular management of large or giant intracranial aneurysms. METHODS A Markov model was constructed to simulate a 60-year-old woman with a large or giant intracranial aneurysm considering a PED, endovascular coiling, or no treatment in terms of neurological outcome, angiographic outcome, retreatment rates, procedural and rehabilitation costs, and rupture rates. Transition probabilities were derived from prior literature reporting outcomes and costs of PED, coiling, and no treatment for the management of aneurysms. Cost-effectiveness was defined, with the incremental cost-effectiveness ratios (ICERs) defined as difference in costs divided by the difference in quality-adjusted life years (QALYs). The ICERs < $50,000/QALY gained were considered cost-effective. To study parameter uncertainty, 1-way, 2-way, and probabilistic sensitivity analyses were performed. RESULTS The base-case model demonstrated lifetime QALYs of 12.72 for patients in the PED cohort, 12.89 for the endovascular coiling cohort, and 9.7 for patients in the no-treatment cohort. Lifetime rehabilitation and treatment costs were $59,837.52 for PED; $79,025.42 for endovascular coiling; and $193,531.29 in the no-treatment cohort. Patients who did not undergo elective treatment were subject to increased rates of aneurysm rupture and high treatment and rehabilitation costs. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about the costs and mortality risks for PED and coiling. Probabilistic sampling demonstrated that PED was the cost-effective strategy in 58.4% of iterations, coiling was the cost-effective strategy in 41.4% of iterations, and the no-treatment option was the cost-effective strategy in only 0.2% of iterations. CONCLUSIONS The authors' cost-effective model demonstrated that elective endovascular techniques such as PED and endovascular coiling are cost-effective strategies for improving health outcomes and lifetime quality of life measures in patients with large or giant unruptured intracranial aneurysm.

Early Physician Follow-Up and Out-of-Hospital Outcomes After Cerebral Aneurysm Treatment in Elderly Patients.

BACKGROUND: The impact of early physician follow-up on out-of-hospital outcomes after cerebral aneurysm treatment has not been studied previously. We investigated the association of early physician follow-up (within 30 days of discharge) with mortality and readmissions for elderly patients undergoing treatment for cerebral aneurysms. METHODS: We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent treatment for cerebral aneurysms from 2007 to 2012. To control for confounding, we used propensity score conditioning and inverse probability weighting, with mixed effects to account for clustering at the Hospital Referral Region level. RESULTS: Of 8703 patients presenting with unruptured aneurysms, 5673 (65.2%) had early physician follow-up, and 3030 (34.8%) did not. Of 3211 patients with subarachnoid hemorrhage, 1504 (46.8%) had early physician follow-up, and 1707 (53.2%) did not. Propensity score-adjusted analysis demonstrated that patients with unruptured aneurysms who visited a physician within 30 days of discharge had lower 3-month mortality (odds ratio [OR] 0.52; 95% confidence interval [95% CI] 0.36-0.74) but a greater rate of 90-day readmissions (OR 1.14; 95% CI 1.03-1.28). Similarly, early follow-up was associated with lower 3-month mortality (OR, 0.33; 95% CI, 0.24-0.46), and a greater rate of 90-day readmissions (OR 1.79; 95% CI 1.02-3.14) for patients presenting with subarachnoid hemorrhage. CONCLUSIONS: In a cohort of Medicare patients undergoing treatment for cerebral aneurysms, we identified an association of early physician follow-up with decreased short-term post-discharge mortality, but increased 90-day readmissions. More studies on the impact of strengthening the post-discharge network on the outcomes of this population are warranted.

Prospective Assessment of a Symptomatic Cerebral Vasospasm Predictive Neural Network Model.

INTRODUCTION: The author introduced a symptomatic cerebral vasospasm (SCV) prediction model built with freeware based on a 91-patient dataset. In a prospective test group of 22 patients at the same hospital, this model outperformed logistic regression models in vasospasm prediction on the basis of the same datasets. One of the model's limitations was a question of reproducibility in other centers. In this report, the author describes his experience with the prospective use of the model at a different hospital with a different population setting. METHODS: Patient data of 25 consecutive cases of aneurysm rupture were prospectively assessed by the model to predict SCV. The prediction was then compared with actual outcome. For the purpose of this report, SCV is defined as a delayed focal decline in neurological examination correlated with an area of radiographic vasospasm. This serves as the primary end point of the predictive model. Each case prediction is reported, along with strength of prediction, which is built into the model. The model's positive predictive value, negative predictive value, and sensitivity and specificity are reported. RESULTS: Twenty-five patients are included in the analysis. Six patients (24%) were diagnosed with SCV. The model predicted 9 patients would have SCV (positive predictive value 67%). The model predicted 16 patients would not have SCV (negative predictive value 100%). The sensitivity of the model was 100%, and the specificity of the model was 84%. DISCUSSION: The present analysis displays the predictive value of a neural network to model symptomatic cerebral vasospasm.

Effectiveness of diagnostic strategies in suspected delayed cerebral ischemia: a decision analysis.

BACKGROUND AND PURPOSE: Delayed cerebral ischemia (DCI) is a serious complication after aneurysmal subarachnoid hemorrhage. If DCI is suspected clinically, imaging methods designed to detect angiographic vasospasm or regional hypoperfusion are often used before instituting therapy. Uncertainty in the strength of the relationship between imaged vasospasm or perfusion deficits and DCI-related outcomes raises the question of whether imaging to select patients for therapy improves outcomes in clinical DCI. METHODS: Decision analysis was performed using Markov models. Strategies were either to treat all patients immediately or to first undergo diagnostic testing by digital subtraction angiography or computed tomography angiography to assess for angiographic vasospasm, or computed tomography perfusion to assess for perfusion deficits. According to current practice guidelines, treatment consisted of induced hypertension. Outcomes were survival in terms of life-years and quality-adjusted life-years. RESULTS: When treatment was assumed to be ineffective in nonvasospasm patients, Treat All and digital subtraction angiography were equivalent strategies; when a moderate treatment effect was assumed in nonvasospasm patients, Treat All became the superior strategy. Treating all patients was also superior to selecting patients for treatment via computed tomography perfusion. One-way sensitivity analyses demonstrated that the models were robust; 2- and 3-way sensitivity analyses with variation of disease and treatment parameters reinforced dominance of the Treat All strategy. CONCLUSIONS: Imaging studies to test for the presence of angiographic vasospasm or perfusion deficits in patients with clinical DCI do not seem helpful in selecting which patients should undergo treatment and may not improve outcomes. Future directions include validating these results in prospective cohort studies.

Aneurysmal subarachnoid hemorrhage: a statewide assessment of outcome based on risk factors, aneurysm characteristics, and geo-demography.

OBJECTIVE: Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating illness with nationwide mortality rates reaching almost 50% within the first 30 days. A study was undertaken to evaluate how treatment modality, physical findings, and geo-demography contribute to the outcome of these cases, including complications and disposition status. METHODS: All cases of aSAH in the fiscal year of 2012 (July 2011-June 2012) at the Medical University of South Carolina and Palmetto Health Richland were studied. These healthcare facilities represent 88.5% of aneurysm treatment in the state of South Carolina. Information including aneurysm properties, Hunt-Hess grade, Fisher grade, and symptoms occurring at and after admission were analyzed. RESULTS: 131 patients (94 women and 37 men) with aSAH were treated. 92.4% of cases were treated endovascularly, with more than a third of all cases using balloon-assisted coiling. Hypertension, tobacco use, and hyperlipidemia were the most prevalent comorbidities. Headache, followed by hydrocephalus, motor disturbance, and nausea/vomiting were the most common presenting symptoms. The most common adverse event occurring after hospital admission was acute respiratory failure followed by urinary tract infection, hydrocephalus, and vasospasm. 42.0% were discharged home and nine patients (6.9%) died during hospitalization. CONCLUSIONS: Previously established risk factors such as hypertension and smoking were identified as the most prevalent comorbidities, with disparity between subgroups, particularly women and African Americans. Endovascular treatment was the primary modality of treatment. Mortality rates were lower than previously reported.

Incremental value of three-dimensional transthoracic echocardiography in the assessment of ruptured aneurysm of anterior mitral leaflet.

The mitral valve aneurysm is a rare complication of infective endocarditis involving mitral or aortic valve. The perforation of the mitral valve aneurysm can lead to significant mitral regurgitation (MR) or thromboembolism, which can cause sudden hemodynamic deterioration. We describe here a case of healed infective endocarditis of the aortic valve with ruptured mitral valve aneurysm that led to severe MR. The aneurysm of the anterior mitral leaflet was diagnosed by two-dimensional transthoracic echocardiography. In this case, three-dimensional transthoracic echocardiography demonstrated the detailed morphology of mitral valve aneurysm which resulted in successful surgical repair of the aneurysm.

Pediatric intracranial aneurysms: current national trends in patient management and treatment.

PURPOSE: Pediatric intracranial aneurysms constitute a medical disease process with many unique features that present unique challenges in orchestrating their treatment. Conflicts exist in pediatric aneurysm literature as to whether endovascular therapy is equivalent to surgical therapy in assuring durable aneurysm obliteration in this population. MATERIALS AND METHODS: The national Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Dataset was queried using the HCUPnet system. Overall trends in length of stay (LOS), associated charges, and in-hospital deaths were analyzed for both subarachnoid hemorrhage (SAH) and nonruptured aneurysms from 2000 to 2009. Trends in the type of procedure, associated LOS, and charges were analyzed for SAH from 2003 to 2009. A p value <0.05 was considered statistically significant. RESULTS: Mean LOS for SAH patients was an additional 7-10 days compared to patients discharged with nonruptured aneurysms. Costs of surgery showed a slight increase, while endovascular procedures also rose 50 % from 2006 to 2009. Interestingly, mean length of stay increased for endovascular procedures from 16.5 to 17.2 days and decreased for surgical procedures from 20.4 to 14.7 days (p < 0.001). CONCLUSIONS: First, in-hospital mortality and hospital length of stay for pediatric subarachnoid hemorrhage have not significantly declined since 1997. Second, in-hospital charges for the management of both ruptured and nonruptured aneurysms rose by over 200 % from 2000 to 2009. Surgical procedures saw a 6 % increase in price, while endovascular procedures sharply rose in costs by 50 %. Finally, endovascular therapy has increased in utilization, while the frequency of surgical therapy has not changed significantly since 2003.

[Emergencies in vascular surgery--a major challenge for the local infrastructure]. / Gefäßchirurgische Notfälle--eine große Herausforderung an die lokale Infrastruktur.

INTRODUCTION: Emergencies in vascular surgery are often life-threatening and require a timely and prompt treatment. Little information is available in the literature about which demands must be made for this on the personnel and infrastructural resources of a hospital. METHODS: All vascular surgical emergency operations of the Surgical University Hospital of Munich - Grosshadern over a period of 2 years were evaluated concerning the emergency category, the leading clinical symptomatology, the genesis, the affected stream area, the intervention time, as well as the need for postoperative intensive medical care. RESULTS: The prevailing procedures were arterial operations (76 %). Ischaemia with 37 % and bleeding with 29 % were the leading clinical symptomatology. Thrombotic events (34 %) showed the most frequent genesis followed by embolism (13 %), stenosis (11 %), aneurysms (10 %) and iatrogenic impairments (10 %). 68 % of the emergencies were treated outside of the daytime working hours. A total of 77 % of the patients needed intensive care treatment or observation after surgery. CONCLUSION: The spectrum and the frequency of emergencies in vascular surgery make high demands on local infrastructure of the hospital and require a fair number of intensive care beds and an adequate and highly trained staff. Only under these conditions can a high quality of treatment be guaranteed for the sometimes life-threatened patients.

Stenosis of the third portion of the duodenum due to bleeding from the anterior pancreaticoduodenal artery: assessment by multiphase contrast-enhanced examination with multislice CT.

BACKGROUND: This study was undertaken to analyze the CT findings for the rare pathological process that stenosis of the third portion of the duodenum was presumed to be caused by bleeding from the anterior pancreaticoduodenal artery. METHODS: Four consecutive patients presenting with frequent vomiting, who did not have well-known underlying disorders causing duodenal stenosis, were retrospectively recruited. Multiphase contrast-enhanced CT examinations were performed with 0.5- or 1-mm collimation. Two radiologists evaluated 2-mm axial and multiplanar reformatted images. RESULTS: In all patients, endoscopy demonstrated severe edematous stenosis of the third portion of the duodenum not associated with ulcer, bleeding, or neoplasm. The following CT findings were observed in all patients: homogenous swelling of the third portion of the duodenum associated with luminal stenosis in un-enhanced images, a band-like area of lower contrast-enhancement surrounding the walls of the third portion of the duodenum in pancreatic-phase images, and stenosis of the celiac axis. In three patients, aneurysms of the anterior pancreaticoduodenal artery in arterial-phase images were depicted. In the remaining patient, the diameter of the artery was irregular. CONCLUSIONS: Multiphase contrast-enhanced CT examination using a multislice CT scanner helps to establish the diagnosis of this pathological process.

Treatment of ruptured intracranial aneurysms: a decision analysis.

The purpose of our study was to evaluate the outcomes of neurosurgical and endovascular treatment of ruptured intracranial aneurysms over a lifetime, based on the results of the International Subarachnoid Aneurysm Trial. We performed a decision analysis, using a Markov model, to evaluate outcomes of neurosurgical and endovascular treatment of ruptured intracranial aneurysms that were suitable for both treatments over a lifetime. We chose 50 years as cohort age. Effectiveness was measured in quality-adjusted life-years (QALYs). In addition, we calculated life expectancy and subarachnoid haemorrhage (SAH)-related mortality and disability rates. Compared with neurosurgery, endovascular treatment increased effectiveness by 1.0 QALY (neurosurgery, 13.1 QALYs; endovascular treatment, 14.1 QALYs) and life expectancy by 0.7 years (neurosurgery, 23.2 years; endovascular treatment, 23.9 years), and decreased SAH-related mortality by 0.4% (neurosurgery, 11.5%; endovascular treatment, 11.1%) and SAH-related disability by 5.0% (neurosurgery, 21.3%; endovascular treatment, 16.3%). One-way sensitivity analysis showed that no parameters influenced the effectiveness of endovascular treatment compared with neurosurgery. For ruptured intracranial aneurysms suitable to both neurosurgical and endovascular treatment, endovascular treatment is more effective than neurosurgery over a lifetime.

Caring for those without words: a perspective on aphasia.

A technical grasp of a medical condition does not always give a person a sense of the emotions behind the disease. Medical professionals, of course, cannot afford to be emotionally invested in every illness they see. Some amount of distance is needed for them to maintain their own emotional health and to give good care to patients. However, emotional or psychological struggles are a large component of a patient's suffering. If these realities are ignored, a medical professional will be much less effective on any level.