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Barnes-Jewish & Washington University
Stroke Center

Stroke and Cerebrovascular Outcomes

Metric: 

In-house Stroke and Death after elective endovascular treatment of unruptured intracranial aneurysms.

2011 – 94 patients treated, no deaths, one hemorrhagic stroke with a complete recovery.

Introduction: 

The endovascular treatment of brain aneurysm started in 1995 with the FDA approval of GDC coils. Our experience and volume with this procedure has grown over time, from less than 20 patients treated in 1996 to approximately 150 in 2011. There are many kinds of complications that may arise during or after these procedures. The aneurysm can rupture from perforation during the coiling, clot may form in the artery or aneurysm during the case and cause an ischemic stroke. Aneurysm coils may dislodge and cause and ischemic stroke. Clot may also form and embolize in the days and weeks after coiling. Finally, there can be serious and not so serious groin access complications ranging from small hematomas to life-threatening retroperitoneal hemorrhages.

Rationale: 

The most frequent serious complication, though, is ischemic stroke from clot forming during or after the procedure. In patients with ruptured aneurysms, there are many other causes of ischemic stroke that are a consequence of the initial aneurysm rupture, so most of the data for QA improvements is from patients with unruptured aneurysms, where we have fewer confounding factors.

Caveat: 

One difficulty in comparing outcomes over time is that not only have devices changed (and new ones have been introduced), but because of advances and experience, we now treat much more challenging aneurysms that are larger, more complicated, and have greater risk of complications. Despite that, our complication rates continue to improve.

Timeline of Quality Monitoring and Changes Made to Date:


1995     

Coils were approved for treatment of intracranial aneurysms, and we began to treat patients at Barnes-Jewish Hospital.


2000  

We reviewed our outcomes from 1996-2000:
  • 173 patients with 185 unruptured aneurysms treated
  • 3 thromboembolic strokes and 3 TIAs within 24 hours of procedure
  • Overall (in patient and 60 days post op) risk of ischemic stroke was 3.9%. (JNS 2002)
Based on this experience and published data from other sites, we added 75 mg clopidogrel po/qd to the 325 mg of aspirin that we routinely pretreated patients with. Another motivation for the dual antiplatelets was the introduction of stents (used as an adjunct for coils to help treat aneurysms with large necks). The stents required more anti-platelet prophylaxis than coils alone.


2003

An online MS Access QA log was created to prospectively record all endovascular therapeutic procedures, including those for brain aneurysms, as well as the in-hospital outcomes. This database has been used, after gaining permission from the IRB, to investigate outcomes of many related questions, including outcomes of patients with unrputured brain aneurysms treated with stent-assisted coiling (JNIS 2012, JNIS 2012).


2005

We reviewed our outcomes from 1996-2005:
  • 684 total patients treated (296 excluded for recent rupture, as well as some for other reasons)
  • 33 patients with 369 procedures included in review
We found that dual antiplatelets significantly reduced the risk of ischemic stroke from (16% (no aspirin or clopidogrel) to 1.9%). There was a trend for more minor bleeding complications (groin access site hematomas). (AJNR 2007 paper)

Since 2005, we have been routinely using dual antiplatelet agents before the procedure, and for some duration after, depending on the devices and outcome of the procedure. For example, if a stent was placed, we would continue dual antiplatelets for at least 3 months. Since 2008, we have been testing different commercially available tests of platelet function. There is good evidence that patients that do not show expected inhibition of platelet function have a higher rate of thromboembolic complications in coronary or cerebrovascular endovascular procedures.


2012

We reviewed our outcomes from 2002 through June 2012:
  • 687 procedures were performed in patients with unruptured brain aneurysms
  • 8 (1.2%) suffered ischemic strokes
  • 5 (0.7%) had hemorrhagic strokes 
One project we pursued in the most recent review was to investigate the question of what the nature and timing of adverse events was in patients in whom the procedure was completed without any apparent complication. We found that nearly all major events happened in the first 4 hours after awakening, and almost none during overnight observation. We may use this information to change our approach to post-operative monitoring in less resource intensive environments. Currently we observe overnight in a 24 hour post anesthesia recover area or the neuro intensive care unit. (Paper in preparation.)

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