• Brian C Deutsch, Sean N Neifert, and John M Caridi.
• Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address: brian.deutsch@icahn.mssm.edu.
• World Neurosurg. 2018 Dec 1; 120: e318-e325.

BackgroundAneurysmal subarachnoid hemorrhage (SAH) can be treated with either endovascular coiling or surgical clipping. The International Subarachnoid Aneurysm Trial (ISAT) found that endovascular coiling provided lower mortality rates at 1-year follow-up, starting a trend toward the endovascular treatment approach for SAH. Subsequently, specific procedural indications have driven an approach to SAH management involving a patient-specific procedural choice. The present study evaluates whether specific indications for these procedures have eliminated the differences in risk-adjusted mortality and in-hospital complications from SAH in a large nationally representative set of hospitalizations from 2013 to 2014.MethodsAll cases of nontraumatic subarachnoid hemorrhage were queried from the National Inpatient Sample using codes from the International Classification of Diseases, 9th edition. These patients were assigned to cohorts based on whether they were treated by surgical clipping or by endovascular coiling. Subsequent univariate and multivariate analyses were used to characterize and compare demographics, in-hospital complications, and total charges between the 2 groups.ResultsIn 2013 to 2014, 6555 patients hospitalized for SAH underwent surgical clipping and 15,350 underwent endovascular coiling. The patients undergoing coiling were older (55.3 vs. 54.1, P = 0.02) and had lower severity scores (3.24 vs. 3.44, P < 0.0001); however, they had higher average risk of mortality scores (2.96 vs. 2.44, P < 0.0001) and longer lengths of stay (19.0 vs. 17.8 days, P = 0.009) than did those undergoing surgical clipping. Multivariate logistic regression analysis comparing clipping to coiling showed no differences in rates of complication (odds ratio [OR]: 0.87; 95% confidence interval [CI]: 0.67-1.13), death (OR: 0.78; 95% CI: 0.57-1.05), or total charges (-$3282, 95% CI: -$8376-$14,941) between both cohorts.ConclusionsConcerns about overzealous use of endovascular coiling in treating SAH after the ISAT stemmed from a lag in condition-specific indications. The allure of endovascular coiling stems from its noninvasiveness and initial results; however, in the years after ISAT, evaluation of SAH conditions led to more patient-specific indications for SAH. The results presented here suggest that more rigorous procedural selection has allowed for an optimization of outcomes for the 2 procedures.Copyright © 2018 Elsevier Inc. All rights reserved.

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