title: Surgical Clipping versus Endovascular Intervention for the Treatment of Subarachnoid Hemorrhage Patients in New York State.
abstract: OBJECTIVE
  Randomized trials have demonstrated a survival benefit for endovascular treatment of ruptured cerebral aneurysms. We investigated the association of surgical clipping and endovascular coiling with outcomes in subarachnoid hemorrhage (SAH) patients in a real-world regional cohort.
  
  
  METHODS
  We performed a cohort study involving patients with ruptured cerebral aneurysms, who underwent surgical clipping, or endovascular coiling from 2009-2013 and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. An instrumental variable analysis was used to investigate the association of treatment technique with outcomes.
  
  
  RESULTS
  Of the 4,098 patients undergoing treatment, 2,585 (63.1%) underwent coiling, and 1,513 (36.9%) underwent clipping. Using an instrumental variable analysis, we did not identify a difference in inpatient mortality [marginal effect (ME), -0.56; 95% CI, -1.03 to 0.02], length of stay (LOS) (ME, 1.72; 95% CI, -3.39 to 6.84), or the rate of 30-day readmissions (ME, -0.30; 95% CI, -0.82 to 0.22) between the two treatment techniques for patients with SAH. Clipping was associated with a higher rate of discharge to rehabilitation (ME, 0.63; 95% CI, 0.24 to 1.01). In sensitivity analysis, mixed effect regression, and propensity score adjusted regression models demonstrated identical results.
  
  
  CONCLUSIONS
  Using a comprehensive all-payer cohort of patients in New York State presenting with aneurysmal SAH we did not identify an association of treatment method with mortality, LOS or 30-day readmission. Clipping was associated with a higher rate of discharge to rehabilitation.
authors.affiliation: Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America.
authors.forename: Kimon
authors.initials: K
authors.lastname: Bekelis
authors.affiliation: Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, United States of America.
authors.forename: Symeon
authors.initials: S
authors.lastname: Missios
authors.affiliation: Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America.
authors.forename: Shannon
authors.initials: S
authors.lastname: Coy
authors.affiliation: Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America.
authors.forename: Redi
authors.initials: R
authors.lastname: Rahmani
authors.affiliation: Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Singer
authors.affiliation: Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America; Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, United States of America.
authors.forename: Todd A
authors.initials: TA
authors.lastname: MacKenzie
mesh_terms: D000328:Adult; D000368:Aged; D057510:Endovascular Procedures; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009518:New York / Q000453:epidemiology; D016017:Odds Ratio; D010351:Patient Discharge; D010359:Patient Readmission; D013345:Subarachnoid Hemorrhage / Q000453:epidemiology* / Q000401:mortality / Q000534:rehabilitation / Q000601:surgery*; D016896:Treatment Outcome