Need for emergency neurosurgical procedures after intracranial endovascular treatment is low


A study recently published in the American Journal of Neuroradiology (AJNR) has revealed that despite the fact that provision for emergency neurosurgical procedures is a mandatory component of centres that perform neuroendovascular procedures, the need for them is quite low.

Investigators Rakesh Khatri and colleagues at the Zeenat Qureshi Stroke Research Center, University of Minnesota, USA, set out to determine the need for emergent neurosurgical procedures following neuroendovascular interventions in two comprehensive stroke centres in settings with such provisions.

Khatri, currently assistant professor at University of Indiana-Fort Wayne, and interventional neurologist with Fort Wayne Neurological Center, Fort Wayne, Indiana, told NeuroNews, “Neuroendovascular surgery is a multidisciplinary specialty, which has been evolving rapidly during the past few decades. As the use of these procedures expands from selected teaching hospitals to various settings, the resources required beyond the neurointerventionalist and angiographic equipment to support safe and effective performance need to be evaluated. In particular, the safety of performing neuroendovascular interventions without emergent neurosurgical backup remains uncertain. We sought to determine the frequency, indications, in-hospital complications, and outcome of patients undergoing intracranial neuroendovascular procedures in which neurosurgical assistance was required on an emergent basis. The purpose of the study was to determine the need for neurosurgical procedures on an emergent basis related to the neuroendovascular interventions.”

The researchers analysed retrospectively collected data from procedure logs and patient charts to identify patients who required immediate (before the termination of the intervention) or adjunctive (within 24 hours of the intervention) neurosurgical procedures related to a neuroendovascular intervention complication. “The types of neurosurgical procedures and in-hospital outcomes of identified patients are reported as an aggregate and per endovascular procedure-type analyses,” they wrote.

Khatri et al reviewed a total of 933 neuroendovascular procedures performed during 3.5 years (2006–2010). They reported that the total number of intracranial procedures carried out was 759. There was a need for emergent neurosurgical procedures in eight patients (0.85% cumulative incidence and 1.05% for major intracranial procedures) (mean age, 46 years; seven were women) and these were categorised as three immediate and five adjunctive procedures, they noted. “There were five in-hospital deaths (62.5%) among these eight patients. Neurosurgical procedures performed were external ventricular drainage placement in six (six out of eight, 75%) patients, decompressive craniectomy in one (12.5%) patient, and both surgical procedures in one (12.5%) patient,” they said.

The findings from the analysis of data from two comprehensive centres led them to conclude that the need for emergent neurosurgical procedures is fairly low among patients undergoing intracranial neuroendovascular procedures. “Survival in such patients despite emergent neurosurgical procedures is quite low,” said Khatri.

NeuroNews asked Khatri some key questions on the study:

Based on the results, do you recommend doing away with the need for compulsory emergent neurosurgical set-up?

No, 24/7 availability of a neurosurgeon remains a compulsory requirement for the centres performing neuroendovascular procedures and managing such patients. Neurosurgeons are required to address direct consequences of primary disease such as decompressive craniectomy for large cerebral infarctions or surgical excision of arteriovenous malformations and to perform procedures such as clipping etc. Our goal of this study was to find the rate of unplanned neurosurgical procedures instituted to directly manage a complication of a neuroendovascular procedure on an emergent basis.

Our study is limited in making a definite conclusion about the impact of such neurosurgical assistance. It may be considered as a preliminary study, and future studies involving larger population samples are needed. There is no doubt that the neurosurgeon remains a very important member of the team managing these patients. Emergent neurosurgical procedures required as a result of neurointervention complications is only one small component of such team-based strategy.

What is your message to interventionalists based on the results of this study?

The key message is that the need for emergent neurosurgical procedures is low among patients undergoing intracranial neuroendovascular procedures. The mortality in patients requiring emergent neurosurgical procedures is quite high despite the intervention. Today, in the era of multidisciplinary care of patients, optimal care of patients with cerebrovascular diseases also requires a team-management strategy involving providers from multiple disciplines. The requirement for emergent neurosurgical procedures among patients undergoing neuroendovascular procedures is only one small component of such optimal and comprehensive and thus “safe” care.

What are the limitations of the study?

Our study has some important limitations. It is a retrospective analysis of patients treated at two academic centres. The number of individual intracranial neuroendovascular procedures evaluated is small, but it includes the latest technology and treatments offered in the present era of technical advancement, thereby providing the latest data. The definition of emergent neurosurgical procedures required within 24 hours of neuroendovascular procedure may have been overly inclusive and neurosurgical procedures that could be accomplished by transferring patients to another facility are probably also included.