Large Hospitals Excel at Stroke Prevention

Stroke care better at large medical centers

(RxWiki News) Technology and procedures to treat unruptured brain aneurysms, which can lead to hemorrhagic stroke caused by cranial bleeding, have improved significantly in the last decade.

Treatment outcomes have not improved with the technology, however, suggesting that higher numbers of procedures performed at smaller community hospitals are producing inferior results. Larger hospitals appear to offer an edge in treatment.

"Seek treatment at state certified stroke centers when possible."

A common minimally invasive treatment for an unruptured brain aneurysm is called endoscopic coiling in which a surgeon inserts a catheter into the thigh's femoral artery. The catheter is guided to the location of the aneurysm, which is then packed with either platinum coils or balloons to prevent blood flow to the area.

Dr. Robert A. Solomon, study co-author, neurosurgeon-in-chief at New York-Presbyterian Hospital/Columbia University Medical and the Byron Stookey Professor of Neurological Surgery, and chairman of the Department of Neurological Surgery at Columbia University College of Physicians and Surgeons, said the problem is not the technology, but the way it is delivered.

He noted that the coiling procedure is hugely helpful for most patients, and that it generally has better outcomes than traditional surgery, which is more invasive. Despite the success, the patient outcomes remain flat.

Coiling has remained popular in smaller hospitals from the perceived ease of the procedure and because of cost concerns. Researchers note that the poor outcomes are borne of technical shortcomings, such as a lack of experienced neurosurgeons, and judgment errors.

"Centers that offer comprehensive cerebrovascular care with both surgical and endovascular capabilities are best equipped to make treatment decisions based on what's best for the patient," noted Dr. Solomon.

During the study researchers compared hospital discharges for unruptured intracranial aneurysms identified through the New York Statewide Database between 2005 and 2007, and also from 1995 to 2000.

They discovered a six-fold increase in the treatment of unruptured intracranial aneurysms since 1995, the majority of which was attributed to coiling at smaller community hospitals where outcomes have remained flat.

Investigators also were surprised to find that overall outcomes had actually worsened for traditional surgical clipping. During this procedure to treat a brain aneurysm, surgeons use a small metal clip to seal off the aneurysm from the outside to stop the blood supply. The clip is left in to lower the future risk of bleeding.

Investigators also attributed the decline in outcomes for the traditional procedure to a wide increase of coiling at smaller hospitals. This is because most cases are now treated with less-invasive coiling, so the patient cases referred for surgery are often increasingly complex, though cerebrovascular surgeons are receiving less practice and training.

The study was recently published in the journal Stroke.

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Review Date: 
February 6, 2012