Unexpectedly, the degree of comprehensive stroke center capabilities did not influence the effect of treatment modality on outcome.
Clipping remains the mainstay of therapy for subarachnoid hemorrhage in Japan, according to the latest update of the J-ASPECT study. The data, from also reveal that clipping is associated with lower in-hospital mortality and a longer hospital stay as well as outcomes and costs that are comparable to coiling.
Unlike in the previous J-ASPECT analysis, published in 2014, the effect of treatment modality on outcomes was not found to be influenced by the comprehensive stroke center capabilities of the treating institutions.
“Numerous studies have compared outcomes between clipping and coiling procedures for patients with subarachnoid hemorrhage (SAH),” wrote authors Koji Iihara MD, PhD, and Ryota Kurogi, MD (Kyushu University, Fukuoka, Japan), in an email to Neurovascular Exchange. “However, most of those studies did not consider that interhospital, interregional, and international factors may contribute to differences in patient outcomes. Moreover, in major RCT studies such as ISAT, many patients were excluded due to strict inclusion criteria.
“The present study,” they said, “is the first to compare outcomes for SAH patients treated with clipping and coiling via a mixed-model analysis of a large nationwide discharge database (DPC database) after adjustment for hospital-level characteristics . . . in addition to patient-level characteristics.”
For their analysis published online May 26, 2017, ahead of print in the Journal of Neurosurgery, the investigators compared outcomes among 5,214 patients with subarachnoid hemorrhage who had been urgently hospitalized at one of 393 institutions in Japan between April 2012 and March 2013. Overall, 3,624 patients were treated with clipping and 1,590 with coiling.
Patients treated with coiling had a higher risk of in-hospital mortality (adjusted OR 1.3; 95% CI 1.06-1.59, P = 0.013). They also had a shorter median hospital stay. There were no differences between the two groups, however, with respect to the proportion who were discharged with significant disability or median medical costs.
Outcomes by Treatment Type
|
|
Clipping (n = 3,624) |
Coiling (n = 1,590) |
P Value |
|
In-Hospital Mortality |
8.7% |
12.4% |
0.013 |
|
Median Hospital Stay, days |
37.0 |
32.0 |
0.001 |
|
mRS 3-6 at Discharge |
42.9% |
46.4% |
NS |
|
Median Medical Costs, USD |
$36,700 |
$35,700 |
NS |
The authors pointed out that the lower in-hospital mortality rate seen with clipping must be balanced against the fact that patients receiving coiling were admitted in poorer clinical condition. Notably, coiling patients were significantly older (mean age 63.5 vs 62 years, P = 0.003), were more likely to have impaired consciousness (30.9% vs 23.7% in comatose state, P < 0.001), and had a higher mean Charlson Comorbidity Index score (4.1 ± 1.6 vs 4.0 ± 1.0, P = 0.034)
Stroke Center Capabilities Did Not Matter
Among the 393 treating institutions, 266 completed questionnaires regarding their comprehensive stroke center capabilities. The investigators calculated a score for each institution based on their responses. The data were then reanalyzed to determine these capabilities’ impact, but the effect of treatment modality on outcome was found to be unaffected.
The authors say that this is unexpected, given their previous work demonstrating reduced in-hospital mortality among institutions with greater capabilities. Instead, it seems “surgeon-related factors such as technical skill and patient-related factors such as aneurysm location, size, and morphology may primarily influence the association between treatment modality and outcome,” they suggest.
Kurogi et al warn that these findings may not be applicable outside of Japan, because the rates of clipping versus coiling vary tremendously from country to country. It is unique to Japan, they point out, that more than 95% of board-certified neuroendovascular physicians are also board-certified neurosurgeons; this has an important influence on the decision to clip or coil.
However, the researchers noted to TCTMD that “in Japan as well as other countries, the number of [patients treated with] coiling has been increasing. Considering that the outcome of coiling in Japan was similar to other countries, this study may shed light on the importance of therapeutic choice for highly-skilled clipping as [an available] treatment for SAH.” As patients who have undergone coiling continue to be studied for longer periods, they add, criteria for selecting appropriate patients for this approach can be modified.
These and other findings of the J-ASPECT study, said the authors, will help inform decision-making as the criteria for official designations as primary and comprehensive stroke centers are developed in Japan.
Source:
Kurogi R, Kada A, Nishimura K, et al. Effect of treatment modality on in-hospital outcome in patients with subarachnoid hemorrhage: a nationwide study in Japan (J-ASPECT Study). J Neurosurg. 2017;Epub ahead of print.
Disclosures:
Iihara and Kurogi report no relevant conflicts of interest.
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