Surgical Clipping versus Endovascular Intervention for the Treatment of Subarachnoid Hemorrhage Patients in New York State

• Published in: PloS one 2015-09, Vol.10 (9), p.e0137946-e0137946
• Main Authors: Bekelis, Kimon, Missios, Symeon, Coy, Shannon, Rahmani, Redi, Singer, Robert J, MacKenzie, Todd A
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aneurysm; Aneurysms; Bias; Cardiovascular disease; Cardiovascular system; Care and treatment; Clinical trials; Codes; Data base management systems; Discharge; Endovascular coiling; Endovascular Procedures; Female; Hemorrhage; Hospital Mortality; Hospitalization; Hospitals; Humans; Length of Stay; Male; Medicine; Middle Aged; Mortality; Neurosurgery; New York - epidemiology; Odds Ratio; Patient Discharge; Patient outcomes; Patient Readmission; Patients; Regression analysis; Regression models; Rehabilitation; Risk factors; Sensitivity analysis; Stroke; Studies; Subarachnoid hemorrhage; Subarachnoid Hemorrhage - epidemiology; Subarachnoid Hemorrhage - mortality; Subarachnoid Hemorrhage - rehabilitation; Subarachnoid Hemorrhage - surgery; Surgery; Treatment Outcome; Variables
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0137946

Randomized trials have demonstrated a survival benefit for endovascular treatment of ruptured cerebral aneurysms. We investigated the association of surgical clipping and endovascular coiling with outcomes in subarachnoid hemorrhage (SAH) patients in a real-world regional cohort. We performed a cohort study involving patients with ruptured cerebral aneurysms, who underwent surgical clipping, or endovascular coiling from 2009-2013 and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. An instrumental variable analysis was used to investigate the association of treatment technique with outcomes. Of the 4,098 patients undergoing treatment, 2,585 (63.1%) underwent coiling, and 1,513 (36.9%) underwent clipping. Using an instrumental variable analysis, we did not identify a difference in inpatient mortality [marginal effect (ME), -0.56; 95% CI, -1.03 to 0.02], length of stay (LOS) (ME, 1.72; 95% CI, -3.39 to 6.84), or the rate of 30-day readmissions (ME, -0.30; 95% CI, -0.82 to 0.22) between the two treatment techniques for patients with SAH. Clipping was associated with a higher rate of discharge to rehabilitation (ME, 0.63; 95% CI, 0.24 to 1.01). In sensitivity analysis, mixed effect regression, and propensity score adjusted regression models demonstrated identical results. Using a comprehensive all-payer cohort of patients in New York State presenting with aneurysmal SAH we did not identify an association of treatment method with mortality, LOS or 30-day readmission. Clipping was associated with a higher rate of discharge to rehabilitation.