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Background and Purpose: For patients with large-vessel occlusion, mechanical thrombectomy (MT) without IV-tPA is a proved strategy. The relative benefit of direct MT versus MT+IV-tPA for patients with indications for IV-tPA is being actively investigated. We used a national inpatient database to assess trends in use and patient profiles after MT+IV-tPA versus mechanical thrombectomy alone., Materials and Methods: The National Inpatient Sample was queried between 2013 and 2018 for patients undergoing mechanical thrombectomy for acute ischemic stroke. Patients who received mechanical thrombectomy alone were compared with those who underwent MT+IV-tPA. The Cochran-Armitage test was conducted to assess the linear trend of use of mechanical thrombectomy alone among the entire cohort and between admissions involving non-White and White patients. All estimates were nationalized using discharge weights., Results: A total of 89,645 weighted admissions were identified pertaining to mechanical thrombectomy for acute ischemic stroke from 2013 to 2018. Of these, 59,935 (66.9%) admissions involved mechanical thrombectomy alone. There was an increase in the trend toward the use of mechanical thrombectomy alone (trend: 3.26%; P  < .001) per year. Multivariable regression analysis regarding patient profiles indicated that patients who identified as Black (OR = 0.83, P  = .001) or Hispanic (OR = 0.79; P  < .001) were more likely to undergo mechanical thrombectomy alone compared with those who identified as White. There was no statistically significant difference in the slope between non-White and White populations receiving mechanical thrombectomy alone (trend: +0.93% in favor of non-White; P  = .096)., Conclusions: Our results indicated that mechanical thrombectomy alone was used more frequently than MT+IV-tPA among patients with acute ischemic stroke. The disparity between those who identify as White and non-White persisted across the years, though it is closing., (© 2021 by American Journal of Neuroradiology.)

Objective: We aimed to identify factors associated with cost of carotid artery stenting (CAS)., Methods: Patient and hospital characteristics affecting cost of admission for CAS were identified using the Vizient national database of hospital-reported outcomes. Patients who underwent CAS for either asymptomatic or symptomatic carotid stenosis were identified using surgical Medicare Severity-Diagnosis Related Groups and appropriate International Classification of Diseases, Ninth Revision and Tenth Revision codes., Results: There were 166 hospitals that reported outcomes from 7369 inpatient admissions for CAS. Each institution reported a mean value for cost related to patient care per admission for CAS; the average cost across all reporting institutions was $12,834.14 (standard error of the mean [SEM], 492.88). Institutions in the lowest 25th percentile with respect to frequency of intensive care unit admission after CAS had lower cost of admission than institutions above the 75th percentile ($10,971.30 [SEM, 460.67] vs $14,992.90 [964.29]; P = .002), without any differences in incidence of stroke during admission (2.2% [SEM, 0.3] vs 2.0% [0.4]; P = .877) or 30-day readmission (1.9% [SEM, 0.4] vs 2.5 [0.6]; P = .329). Admissions for patients with symptomatic stenosis were more expensive than those with asymptomatic stenosis ($20,462.10 [SEM, 819.93] vs $11,285.20 [347.11]; P < .001). Obesity was also associated with greater costs of admission ($14,176.20 [SEM, 597.13] vs $12,287.10 [395.73]; P < .001)., Conclusions: Admission to an intensive care unit, symptomatic stenosis, and obesity were associated with increased costs in patients undergoing CAS. These data may aid in identifying opportunities to improve the cost-effectiveness of this procedure., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Acute coronary syndromes account for half of all deaths secondary to cardiovascular disease and represent a significant economic burden in the United States. Therefore, assessing hospitalization costs relative to Medicare reimbursement for these patients is important in understanding the impact of these patients on hospitals. We hypothesized that hospitalization costs for acute myocardial infarction patients treated with percutaneous coronary intervention (PCI) were higher than their associated Medicare payments., Methods: Using the Nationwide Inpatient Sample, we evaluated hospitalization costs for patients treated with PCI from 2001 through 2009 by multiplying hospital charges by the group average cost-to-charge ratio for each patient's hospitalization. Primary end points examined were total hospital costs and trends over time, which were correlated with clinical outcomes and insurance payments. Costs were inflation adjusted with 2009 as the reference year., Results: Median hospitalization costs of PCI increased from $15 889 (interquartile range [IQR] = $12 057-$21 204) in 2001 to $19 349 (IQR = $14 660-$26 282) in 2009. From 2004 to 2009, inflation-adjusted costs for PCI decreased at a rate of 0.3% per year. In 2009, a total of 265,531 patients received PCI for acute myocardial infarction. Of these, 143 654 were <65 years old, and 121 876 were ≥65 years old. Average 2009 Medicare payments ranged from $9303 to $17 500 depending on the Medicare Severity-Diagnosis Related Groups (MS-DRG) billed, leaving hospitals at a loss of anywhere from $4493 to $7940 per patient when comparing costs and reimbursements across all included MS-DRG codes., Conclusions: Hospitalization costs for patients treated with PCI have been stabilizing over the last few years; however, there still remains a significant disparity between Medicare reimbursements and hospitalization costs, which has potential implications on patient outcomes, quality of care, and hospital sustainability., (© 2014 Wiley Periodicals, Inc.)

Background and Purpose: Vertebroplasty and kyphoplasty are frequently utilized in the treatment of symptomatic vertebral body fractures. While prior studies have demonstrated disparities in the treatment of back pain and care for osteoporotic patients, disparities in spine augmentation have not been investigated. We investigated racial and health insurance status differences in the use of spine augmentation for the treatment of osteoporotic vertebral fractures in the United States., Materials and Methods: Using the Nationwide Inpatient Sample from 2005 to 2010, we selected all discharges with a primary diagnosis of vertebral fracture (International Classification of Diseases-9 code 733.13). Patients who received spine augmentation were identified by using International Classification of Diseases-9 procedure code 81.65 for vertebroplasty and 81.66 for kyphoplasty. Patients with a diagnosis of cancer were excluded. We compared usage rates of spine augmentation by race/ethnicity (white, black, Hispanic, and Asian/Pacific Islander) and insurance status (Medicare, Medicaid, self-pay, and private). Comparisons among groups were made by using χ(2) tests. A multivariate logistic regression analysis was fit to determine variables associated with spine augmentation use., Results: A total of 228,329 patients were included in this analysis, of whom 129,206 (56.6%) received spine augmentation. Among patients with spine augmentation, 97,022 (75%) received kyphoplasty and 32,184 (25%) received vertebroplasty; 57.5% (92,779/161,281) of white patients received spine augmentation compared with 38.7% (1405/3631) of black patients (P < .001). Hispanic patients had significantly lower spine augmentation rates compared with white patients (52.3%, 3777/7222, P < .001) as did Asian/Pacific Islander patients (53.1%, 1784/3361, P < .001). The spine augmentation usage rate was 57.2% (114,768/200,662) among patients with Medicare, significantly higher than that of those with Medicaid (43.9%, 1907/4341, P < .001) and those who self-pay (40.2%, 488/1214, P < .001)., Conclusions: Our findings demonstrate substantial racial and health insurance-based disparities in the inpatient use of spinal augmentation for the treatment of osteoporotic vertebral fracture., (© 2014 by American Journal of Neuroradiology.)

Background and Purpose: Previous studies have demonstrated that socioeconomic disparities in the treatment of cerebrovascular diseases exist. We studied a large administrative data base to study disparities in the utilization of mechanical thrombectomy for acute ischemic stroke., Materials and Methods: With the utilization of the Perspective data base, we studied disparities in mechanical thrombectomy utilization between patient race and insurance status in 1) all patients presenting with acute ischemic stroke and 2) patients presenting with acute ischemic stroke at centers that performed mechanical thrombectomy. We examined utilization rates of mechanical thrombectomy by race/ethnicity (white, black, and Hispanic) and insurance status (Medicare, Medicaid, self-pay, and private). Multivariate logistic regression analysis adjusting for potential confounding variables was performed to study the association between race/insurance status and mechanical thrombectomy utilization., Results: The overall mechanical thrombectomy utilization rate was 0.15% (371/249,336); utilization rate at centers that performed mechanical thrombectomy was 1.0% (371/35,376). In the sample of all patients with acute ischemic stroke, multivariate logistic regression analysis demonstrated that uninsured patients had significantly lower odds of mechanical thrombectomy utilization compared with privately insured patients (OR = 0.52, 95% CI = 0.25-0.95, P = .03), as did Medicare patients (OR = 0.53, 95% CI = 0.41-0.70, P < .0001). Blacks had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR = 0.35, 95% CI = 0.23-0.51, P < .0001). When considering only patients treated at centers performing mechanical thrombectomy, multivariate logistic regression analysis demonstrated that insurance was not associated with significant disparities in mechanical thrombectomy utilization; however, black patients had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR = 0.41, 95% CI = 0.27-0.60, P < .0001)., Conclusions: Significant socioeconomic disparities exist in the utilization of mechanical thrombectomy in the United States.

Background and Purpose: Patient age substantially influences treatment decisions for ruptured cerebral aneurysms. It would be useful to understand national age-related trends of treatment techniques and outcomes in patients treated for ruptured cerebral aneurysm in the United States., Materials and Methods: Using the US Nationwide Inpatient Sample, we evaluated trends in treatment technique (clipping versus coiling) and discharge status of patients undergoing clipping or coiling of ruptured cerebral aneurysms between 2001 and 2009. Outcomes were evaluated in relation to 4 age strata: 1) younger than 50 years of age, 2) 50-64 years of age, 3) 65-79 years of age, and 4) patients 80 years or older. We compared outcomes between treatment groups for patients treated between 2001-2004 with those treated between 2005-2009., Results: A significant increase in the proportion of patients undergoing endovascular coiling between 2001 and 2009 was noted for all age groups (P < .0001). For both clipped and coiled patients, mortality and the proportion of patients discharged to long-term facilities increased with age. Overall mortality for patients clipped and coiled decreased modestly for all age groups, and overall proportions of patients discharged home increased modestly (P < .01) for all age groups except those older than 80 years of age., Conclusions: Between 2001 and 2009, there has been a significant increase in the proportion of patients with ruptured aneurysms undergoing endovascular coiling rather than aneurysm clipping. This increase was more pronounced in older patients. Mortality from aneurysmal subarachnoid hemorrhage decreased during the past decade, regardless of aneurysm treatment technique.

Background: Outcomes of cerebral venous thrombosis (CVT) vary from full recovery to death. Few studies have been performed examining epidemiologic and medical risk factors associated with high mortality in CVT. In this study, we examined the National Inpatient Sample (NIS) to determine the epidemiologic and medical risk factors associated with increased mortality from CVT., Materials and Methods: Using the NIS from 2001 to 2008, patients who suffered from CVT were identified using the ICD-9 codes 437.6 (nonpyogenic thrombosis of intracranial venous sinus), 325 (phlebitis and thrombophlebitis of intracranial venous sinuses) and 671.5 (peripartum phlebitis and thrombosis, cerebral venous thrombosis, thrombosis of intracranial venous sinus). We analyzed the associations of demographic factors, risk factors, comorbidities, complications of CVT, and therapeutic interventions with in-hospital mortality. We performed a multivariate logistic regression analysis to determine which variables were independently associated with in-hospital mortality., Results: 11,400 patients were hospitalized with CVT between 2001 and 2008. Two-hundred and thirty-two (2.0%) suffered in-hospital mortality. Patients 15-49 years old had the lowest mortality rate (1.5%) compared with 2.8% for patients aged 50-64 (p < 0.001) and 6.1% for patients ≥65 years old (p < 0.001). The most common condition associated with CVT was pregnancy/puerperium (24.6%), and these women had a low mortality rate (0.4%). On multivariate analysis, the comorbidity most strongly associated with increased risk of mortality was sepsis (mortality rate 15.6%, OR = 7.5, 95% CI = 4.79-11.53, p < 0.001). Malignancy, underlying autoimmune disease and substance abuse were also independently associated with mortality, but with lower mortality rates (<5%). Complications associated with increased risk of mortality included paralysis (8.0%, OR = 3.4, 95% CI = 3.17-6.96, p < 0.001), intracranial hemorrhage (8.7%, OR = 5.4, 95% CI = 4.38-7.96, p < 0.001), and hydrocephalus (15.0%, OR = 3.2, 95% CI = 5.54-15.11, p = 0.004). Demographic variables associated with decreased mortality on multivariate analysis were male gender (2.1%, OR = 0.62, 95% CI = 0.43-0.87, p = 0.006) and Asian/Pacific Islander race (OR = 0.00, 95% CI = 0-0.27, p < 001)., Conclusions: CVT is associated with a low in-hospital mortality rate. Amongst patients suffering CVT, male gender and Asian/Pacific Islander race were independently associated with lower odds of in-hospital mortality when compared to their female and white counterparts, respectively. Septic patients with CVT have the greatest risk of in-hospital mortality. Hydrocephalus, intracranial hemorrhage, and motor deficits are also associated with higher risk of death. Our results build on previous evidence that serves to define a group of patients with CVT at high risk of early death., (Copyright © 2013 S. Karger AG, Basel.)

Background and Purpose: Previous studies have suggested seasonal variations in rates of spontaneous rupture of intracranial aneurysms, leading to potentially devastating SAH. In an effort to identify a seasonal effect, variation in SAH incidence and in-hospital mortality rates were examined as they relate to admission month, temperature, and climate using HCUP's Nationwide Inpatient Sample., Materials and Methods: Cases of nontraumatic SAH and subsequent in-hospital mortality were extracted from the 2001-2008 NIS and associated with month of occurrence, local average monthly temperatures, and USDA climate zone. Multivariate regression analysis was used to study how admission month, temperature, and climate affected SAH admission and mortality rates., Results: Among 57,663,486 hospital admissions from the 2001-2008 NIS, 52,379 cases of spontaneous SAH (ICD-9-CM 430) and 13,272 cases of subsequent in-hospital mortality were identified. SAH incidence and in-hospital mortality rates were not significantly correlated with a monthly/seasonal effect (incidence, χ(2) = 2.94, P = .99; mortality, χ(2) = 6.91, P = .81). However, SAH incidence significantly varied with climate (P < .0001, zones 11 and 7) but not with temperature (P = .1453), whereas average monthly temperature and climate had no significant correlation with in-hospital mortality (temperature, P = .3005; climate, P = .0863)., Conclusions: We identified no significant monthly or temperature-related effect in the incidence of SAH. Our data suggest that certain climate zones within the United States may be associated with significantly different SAH incidence, but the origins of these differences remain unclear and are probably unrelated to meteorologic variables.

Background and Purpose: Endovascular and surgical options are both available for treatment of ruptured cerebral aneurysms. Knowledge of the costs relative to Medicare reimbursement for hospitalization of these patients is important for understanding the economic impact of these patients on hospitals., Materials and Methods: Using the NIS, we identified hospitalizations for clipping and coiling of ruptured cerebral aneurysms from 2001 to 2008 by cross-matching ICD-9 codes for diagnosis of ruptured aneurysm with procedure codes for clipping or coiling of cerebral aneurysms. Hospital costs for 2008 were correlated with age, sex, and discharge status. For discharges of Medicare patients, we compared Medicare payments with costs for respective MS-DRG., Results: For 2008, the average Medicare payment for craniotomy and endovascular intracranial procedures without complication (MS-DRG 22) was $30,380. Medicare discharges with DRG 22, for patients undergoing clipping had median costs of $59,799 in 2008. Those undergoing coiling had median costs of $36,543. Reimbursement for discharges with complications or comorbidities (MS-DRG 21) was $36,304. Median costs for hospitalization of clipped patients with MS DRG 21 was $79,916 and for coiled patients, $56,910. Reimbursement for MS-DRG 20 (major complications or comorbidities) was $41,748, with patients undergoing clipping incurring a median cost of $83,737 and those undergoing coiling incurring a median cost of $83,277., Conclusions: Hospitalization costs for patients undergoing clipping and coiling of unruptured cerebral aneurysms are substantially higher than Medicare payments.

Background and Purpose: Hospitals struggle to provide care for elderly patients based on Medicare payments. Amid concerns of inadequate reimbursement, we sought to evaluate the hospitalization costs for recipients of CEA and CAS placement, identify variables associated with increased costs, and compare these costs with Medicare reimbursements., Materials and Methods: All CEA and CAS procedures were extracted from the 2001-2008 NIS. Average CMS reimbursement rates for CEA and CAS were obtained from www.CMS.gov. Annual trends in hospital costs were analyzed by Sen slope analysis. Associations between LOS and hospital costs with respect to sex, age, discharge status, complication type, and comorbidity were analyzed by using the Wilcoxon rank sum test. Least-squares regression models were used to predict which variables had the greatest impact on LOS and hospital costs., Results: The 2001-2008 NIS contained 181,200 CEA and 12,485 CAS procedures. Age and sex were not predictive of costs for either procedure. Among favorable outcomes, CAS was associated with significantly higher costs compared with CEA (P < .0001). Average Medicare payments were $1,318 less than costs for CEA and $3,241 less than costs for CAS among favorable outcomes. Greater payment-to-cost disparities were noted for both CEA and CAS in patients who had unfavorable outcomes., Conclusions: The 2008 Medicare hospitalization payments were substantially less than median hospital costs for both CAS and CEA. Efforts to decrease hospitalization costs and/or increase payments will be necessary to make these carotid revascularization procedures economically viable for hospitals in the long term.

Background and Purpose: Both endovascular and surgical options are available for treatment of unruptured cerebral aneurysms. We conducted a study to determine the costs versus Medicare reimbursement for hospitalization of these patients, which is important information for understanding the economic impact of these patients on hospitals., Materials and Methods: Using the NIS, we identified hospitalizations for clipping and coiling of unruptured cerebral aneurysms from 2001 to 2008 by cross-matching ICD-9 codes for diagnosis of unruptured aneurysm with procedure codes for clipping or coiling of cerebral aneurysms and excluding all patients with subarachnoid hemorrhage and intracerebral hemorrhage. Hospital costs for 2008 were correlated with age, sex, and discharge status and compared with Medicare payments., Results: Costs of both clipping and coiling have increased from 2001 to 2008. The median 2008 hospital costs were $23,574 (IQR, $18,233-$29,941) for clipping and $25,734 (IQR, $17,436-$35,846) for coiling without complications, which were higher than the average Medicare payment of $12,599. The median hospital costs were $36,188 (IQR, $21,831-$55,308) for clipping and $40,502 (IQR, $24,289-$50,108) for coiling treatments complicated by major morbidity and $68,165 (IQR, $32,972-$100,211) for clipping and $56,020 for coiling treatments complicated by mortality, which were higher than the average Medicare payment for patients with major complications and comorbidities of $22,946. In multivariate analysis, female sex was associated with higher costs for coiling (P = .02), and poor discharge status was associated with higher costs for both clipping (P < .001) and coiling (P < .001)., Conclusions: Hospitalization costs for patients undergoing clipping and coiling of unruptured cerebral aneurysms are substantially higher than Medicare payments.

Background and Purpose: Endovascular therapy has increasingly become an acceptable option for treatment of unruptured aneurysms. To better understand the recent trends in the use of and outcomes related to coiling compared with clipping for unruptured aneurysms in the United States, we evaluated the NIS., Materials and Methods: Hospitalizations for clipping or coiling of unruptured cerebral aneurysms from 2001 to 2008 were identified by cross-matching ICD codes for the diagnosis of unruptured aneurysm (437.3) with procedural codes for clipping (39.51) or coiling (39.52, 39.79, or 39.72) of cerebral aneurysms and excluding all patients with a diagnosis of subarachnoid hemorrhage (430) and intracerebral hemorrhage (431). Mortality and discharge to a long-term facility were evaluated for both clipping and coiling patient populations., Results: The fraction of unruptured aneurysms treated with coiling increased from 20% in 2001 to 63% in 2008. For surgical clipping, the percentage of patients discharged to long-term facilities was 14.0% (4184/29,918) compared with 4.9% (1655/34,125) of coiled patients (P < .0001). Clipped patients also had a higher mortality rate because 344 (1.2%) clipped patients died compared with 215 (0.6%) coiled patients (P < .0001). Between 2001 and 2008, the overall number of adverse outcomes from treatment had decreased from 14.8% to 7.6%., Conclusions: The use of endovascular coiling relative to surgical clipping of unruptured intracranial aneurysms is associated with decreasing periprocedural morbidity and mortality among patients treated in the United States from 2001 to 2008.

Background and Purpose: Practice patterns vary widely among centers with regard to the treatment of unruptured aneurysms. The purpose of the current study was to correlate outcome data with practice patterns, specifically the proportion of unruptured aneurysms treated with neurosurgical clipping versus endovascular coiling., Materials and Methods: Using the NIS, we evaluated outcomes of patients treated for unruptured aneurysms in the United States from 2001 to 2007. Hospitalizations for clipping or coiling of unruptured cerebral aneurysms were identified by cross-matching ICD codes for diagnosis of unruptured aneurysm with procedure codes for clipping or coiling of cerebral aneurysms. Mortality and morbidity, measured as "discharge to long-term facility," were evaluated in relation to the fraction of cases treated with coils versus clipping as well as the annual number of unruptured aneurysms treated by individual hospitals and individual physicians., Results: Markedly lower morbidity (P < .0001) and mortality (P = .0015) were noted in centers that coiled a higher percentage of aneurysms compared with the proportion of aneurysms clipped. Multivariate analysis showed that greater annual numbers of aneurysms treated by individual practitioners were significantly related to decreased morbidity (OR = 0.98, P < .0001), while the association between morbidity and the annual number of aneurysms treated by hospitals was not significant (OR = 1.00, P = .89)., Conclusions: Centers that treated a higher percentage of unruptured aneurysms with coiling compared with clipping achieved markedly lower rates of morbidity and mortality. Our results also confirm that treatment by high-volume practitioners is associated with decreased morbidity.

Background and Purpose: The purpose of this study was to determine the publication fate of submissions previously rejected from the American Journal of Neuroradiology (AJNR) to provide guidance to authors who receive rejection notices., Materials and Methods: A retrospective search by using MEDLINE of all submissions rejected from AJNR in 2004 was performed to identify subsequently published manuscripts. The fate of subsequently published manuscripts was analyzed as a function of submission type (major study, technical note, or case report), publication delay, publishing journal type (neuroradiology, general radiology, or clinical neuroscience journal), impact factor, publication volume, and circulation volume., Results: Of the 554 rejected submissions to AJNR, 315 (56%) were subsequently published in 115 different journals, with the journal Neuroradiology publishing the greatest number of articles (37 [12%] of 315). The mean publication delay was 15.8 +/- 7.5 months. Major studies were more likely than case reports to be subsequently published (P = .034), but all 3 subtypes were published at rates greater than 50%. Radiologic journals collectively published approximately 60% of subsequent publications, whereas neurosurgery and neurology journals published 27% of rejected manuscripts. The mean impact factor of journals subsequently publishing rejected manuscripts was 1.8 +/- 1.3 (AJNR = 2.5), and 24 (7.5%) manuscripts were subsequently published in journals with higher impact factors than AJNR., Conclusions: These findings should give hope to authors receiving a rejection from AJNR, because greater than 50% of articles rejected from AJNR are subsequently published within 2-3 years, irrespective of publication type, into high-quality journals.

Object: The aim of this study was to determine the prevalence of cerebral saccular aneurysms in patients with persistent primitive trigeminal artery (PPTA). The prevalence of cerebral saccular aneurysms in patients with PPTA previously has been reported to be 14 to 32%, but this rate range is unreliable because it is based on collections of published case reports rather than a series of patients chosen in an unbiased manner., Methods: The authors retrospectively evaluated their own series of 34 patients with PPTA to determine the prevalence of cerebral aneurysms in this population. The prevalence of intracranial aneurysms in patients with PPTA was approximately 3% (95% confidence interval 0-9%)., Conclusions: The prevalence of intracranial aneurysms in patients with PPTA is no greater than the prevalence of intracranial aneurysms in the general population.