title: Cranial neurosurgery procedure utilization among patients with acute ischemic stroke.
abstract: BACKGROUND
  Concerns about ready access to neurosurgery after acute ischemic stroke (AIS) may delay or prevent intravenous thrombolysis, thereby leading to poor outcomes. A randomized trial exploring the need for back-up neurosurgery in AIS is unlikely. However, insight may be gained from routine clinical practice. We analyzed the odds and temporal trends of cranial neurosurgery procedure use in patients with AIS using a large U.S. administrative database.
  
  
  METHODS
  Data from AIS patients in the Nationwide Inpatient Sample (October 1998 to 2006) who underwent a cranial neurosurgical procedure were analyzed. Multivariate logistic regression with covariate adjustment was used for statistical analysis. Results were stratified by thrombolysis status. Intracerebral hemorrhage (ICH) was used as a key covariate.
  
  
  RESULTS
  Intravenous thrombolysis use increased significantly over time (0.8% to 2.5%; P<.001). Cranial neurosurgical procedures were observed infrequently but increased significantly over time (0.12% to 0.19%; P=.0013), and thrombolysis doubled the odds of a procedure (odds ratio 2.18; 95% confidence interval 1.48-3.21; P<.001). However, thrombolysis only significantly increased the odds of a neurosurgical procedure in the absence of ICH (P<.001).
  
  
  CONCLUSIONS
  Thrombolysis should probably not be withheld from eligible AIS patients, even if a concern exists about the lack of readily available neurosurgery, because neurosurgical procedure use is low in routine clinical practice, even after intravenous thrombolysis. Future studies and prospective data might help define the need for standby neurosurgery after AIS and provide further focus on the specific linkage to ICH as a possible mediator variable.
authors.affiliation: Stroke Center, St. Rose Dominican Hospitals-Siena Campus, Henderson, Nevada. Electronic address: scottselco@gmail.com.
authors.forename: Scott L
authors.initials: SL
authors.lastname: Selco
authors.forename: Daniela
authors.initials: D
authors.lastname: Markovic
authors.forename: Bruce
authors.initials: B
authors.lastname: Ovbiagele
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000601:surgery*; D003399:Craniotomy / Q000706:statistics & numerical data; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012959:Socioeconomic Factors; D020521:Stroke / Q000601:surgery*; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator