Guest Post by Nicholas Bambakidis, MD
Professor of Neurosurgery and Director, Cerebrovascular and Skull Base Surgery
Residency Program Director, Neurological Surgery
University Hospitals Case Medical Center
The Dartmouth Institute recently published a review of cerebral aneurysm care as part of their “Atlas of Health Care” series. The report, “Variation in the Care of Surgical Conditions: Cerebral Aneurysms A Dartmouth Atlas of Health Care,” focuses on unwarranted variation of surgical care in the United States, which is not explained by patient needs or preferences. The review includes recent literature on outcomes in the treatment of both ruptured and unruptured cerebral aneurysms. The report found that the frequency of endovascular coiling of aneurysms has increased on average in recent years, but after the initial surge, the use of coiling has stabilized to between 60-70 percent of aneurysm treatment. Likewise, after an initial decline in aneurysm clipping, rates have stabilized, and clipping continues to be a mainstay of aneurysm treatment.
The aforementioned findings reflect the realization that emerging endovascular technologies are insufficient to adequately treat all aneurysms and lead to significant rates of recurrence and the need for retreatment in some cases. It also points out the importance of individualizing treatment based on patient-specific criteria. The study found significant variation regionally across the United States with respect to rates of clipping vs. coiling, which, unfortunately, may be related to other factors such as physician training, experience, and preference.
In order to minimize such extraneous influences, it is important that high quality specialized care in all aneurysm treatment modalities be available at centers of excellence, such as Comprehensive Stroke Centers (CSC) that are certified by the Joint Commission. Unfortunately, the Cerebrovascular Coalition — which includes national physician specialty societies (including the AANS and CNS) whose members treat stroke patients — is concerned that the current CSC criteria are insufficient to guarantee appropriate expertise in all aneurysm treatment modalities. It is, therefore, imperative that the Joint Commission modify these standards to best meet the needs of patients.
The Dartmouth study also points out that the best outcome with respect to aneurysm treatment (either clipping or coiling) remains controversial and is still an important gap in knowledge. The study proposes further research into outcomes through the use of clinical data registries. Importantly, the authors highlighted the launch of the cerebrovascular module of the National Neurosurgery Quality and Outcomes Database (N2QOD) as an ideal effort in this regard. This reinforces the notion, in the absence of complete registry data, multimodality therapy must be available in order to best offer adequate treatment options to patients with cerebral aneurysms and to avoid unwarranted variation of aneurysm care which is not grounded in sound scientific rationale.
At the end of the day, patients who receive a new diagnosis of cerebral aneurysm (especially unruptured) face a difficult road to informed decision-making. Understanding their needs, addressing their concerns, and creating new quality paradigm, which promotes the use of clinical outcome registries, will be central to the process of minimizing variability and orchestrating a patient-centered approach to cerebral aneurysm treatment.