title: Treatment of ruptured and unruptured cerebral aneurysms in the USA: a paradigm shift.
abstract: BACKGROUND
  Integration of data from clinical trials and advancements in technology predict a change in selection for treatment of patients with cerebral aneurysm.
  
  
  OBJECTIVE
  To describe patterns of use and in-hospital mortality associated with surgical and endovascular treatments of cerebral aneurysms over the past decade.
  
  
  METHODS
  The data are 34 899 hospital discharges with a diagnosis of ruptured or unruptured cerebral aneurysm from 1998 to 2007 identified from the Nationwide Inpatient Sample (NIS). The rates of endovascular coiling and surgical clipping and in-hospital mortality among patients with an aneurysm are examined over a decade by hospital and patient demographic characteristics.
  
  
  RESULTS
  From 1998 to 2007, 20 134 discharges with a ruptured aneurysm and 14 765 discharges with an unruptured aneurysm were identified. Over this decade, the number of patients discharged with a ruptured aneurysm was stable while the number discharged with an unruptured aneurysm increased significantly. The use of endovascular coiling increased at least twofold for both groups of patient (p<0.001) with the majority of unruptured aneurysms treated with coiling by 2007. Although whites were more likely than non-whites to undergo coiling versus clipping for a ruptured aneurysm (OR=1.30; 95% CI 1.13 to 1.48) and men with unruptured aneurysms were more likely than women to undergo coiling (OR=1.26; 95% CI 1.13 to 1.40), by 2007 differences in treatment selection by gender and racial subgroups were decreased or statistically non-significant. Over time the use of coiling spread from primarily large, teaching hospitals to smaller, non-teaching hospitals.
  
  
  CONCLUSIONS
  The majority of unruptured aneurysms in the USA are now treated with endovascular coiling. Although surgical clipping is used for treatment of most ruptured aneurysms, its use is decreasing over time. Dissemination of endovascular procedures appears widespread across patient and hospital subgroups.
authors: Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts 02215, USA. nlin1@partners.org
authors: Ning
authors: N
authors: Lin
authors: Kevin S
authors: KS
authors: Cahill
authors: Kai U
authors: KU
authors: Frerichs
authors: Robert M
authors: RM
authors: Friedlander
authors: Elizabeth B
authors: EB
authors: Claus
mesh_terms: D000367:Age Factors; D000368:Aged; D017542:Aneurysm, Ruptured / Q000191:economics / Q000601:surgery*; D004059:Diffusion of Innovation; D005260:Female; D019538:Health Care Surveys; D006276:Health Facility Size; D017052:Hospital Mortality; D006801:Humans; D002532:Intracranial Aneurysm / Q000191:economics / Q000453:epidemiology / Q000601:surgery*; D007902:Length of Stay; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000191:economics / Q000706:statistics & numerical data / Q000639:trends*; D012959:Socioeconomic Factors; D013525:Surgical Instruments; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology