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2. Radiation exposure in patients with subarachnoid hemorrhage: a quality improvement target

Author

Judith M, Wong, Allen L, Ho, Ning, Lin, Georgios A, Zenonos, Christopher B, Martel, Kai, Frerichs, Rose, Du, and William B, Gormley

Subjects
Male, Risk Management, Fluoroscopy, Humans, Female, Middle Aged, Subarachnoid Hemorrhage, Radiation Dosage, Radiation Injuries, Aged, Cerebral Angiography, Quality of Health Care, Retrospective Studies
Abstract

The care of patients with subarachnoid hemorrhage (SAH) has improved dramatically over the last decades. These gains are the result of improved microsurgical, endovascular, and medical management techniques. This intensive management subjects patients to multiple radiographic studies and thus increased radiation exposure. As greater understanding of the risks of radiation exposure develops, physicians must be better equipped to balance the need for optimal SAH management with the minimization of patient exposure to radiation from imaging studies. The goal in the current study was to determine if there is an opportunity for a reduction in radiation dose without a change in the quality of treatment in patients with SAH.A retrospective chart review of all patients hospitalized for SAH at the Brigham and Women's Hospital in the period from January 1, 2009, to August 31, 2010, was performed. The authors calculated cumulative and imaging study-specific radiation doses, determined the time of day that imaging studies were performed, and surveyed neurosurgeons regarding issues surrounding imaging-related radiation exposure.The data for 77 patients were analyzed. The mean cumulative radiation dose during hospitalization was 2.76 Gy per patient (range 0.46-8.32 Gy). The mean radiation exposure from each CT, CT angiography (CTA), and angiography study was 0.08, 0.29, and 0.77 Gy (ranges 0.02-0.40, 0.15-0.99, and 0.11-4.36 Gy, respectively). Subgroup analysis of the top quartile of patients in terms of total radiation dose revealed a mean cumulative radiation dose of 4.78 Gy (range 3.42-8.32 Gy), mean cumulative number of CT and CTA scans of 14, and mean CT or CTA scan per day of 0.5 (maximum 0.8). Seventeen percent of the noncontrast head CT studies were performed just prior to morning rounds, more than double the 8% expected rate at random. Thirty-four percent of the repeat noncontrast head CTs did not show any change between scans, as documented on radiology reports. When surveyed, a majority of neurosurgeons incorrectly estimated the radiation dose typically received from CT, CTA, and angiography studies, and 65% asserted that radiation exposure is "not important" or only "somewhat important" when considering whether to order an imaging study.Study findings suggested that patients with SAH have significant imaging-related exposure to radiation. The authors believe it is possible to continue the current improved outcomes in SAH with a significant reduction in radiation exposure from imaging studies. This analysis highlights the significance of accurate assessment of radiation exposure as a quality improvement target.

Published
2013

3. Contributors

Author

Frank L. Acosta, P. David Adelson, John R. Adler, ., Kamran V. Aghayev, Manish K. Aghi, Basheal M. Agrawal, Manmeet S. Ahluwalia, Faiz Ahmad, Ellen Air, Pablo Ajler, Felipe C. Albuquerque, Arun P. Amar, Luca Amendola, Christopher Ames, Beejal Y. Amin, Sepideh Amin-Hanjani, Joshua M. Ammerman, William S. Anderson, Ronald I. Apfelbaum, Michael L.J. Apuzzo, Rocco Armonda, Paul M. Arnold, Harel Arzi, Ashok R. Asthagiri, Kurtis Auguste, Tariq E. Awad, Khaled M. Aziz, Tipu Aziz, Joachim M. Baehring, Mirza N. Baig, Roy Bakay, Perry A. Ball, Stefano Bandiera, Nicholas M. Barbaro, Frederick G. Barker, Daniel L. Barrow, Sachin Batra, Joshua Bederson, Kimon Bekelis, Carlo Bellabarba, Lorenzo Bello, Allan J. Belzberg, Bernard R. Bendok, Ludwig Benes, Edward C. Benzel, Helmut Bertalanffy, Chetan Bettegowda, Ravi Bhatia, Sanjay Bhatia, Allen T. Bishop, Keith L. Black, Lewis S. Blevins, George T. Blike, Ari Blitz, Göran C. Blomstedt, Benjamin Blondel, Kofi Boahene, Bernardo Boleaga, Markus Bookland, Stefano Boriani, Christopher M. Boxell, Henry Brem, Albino Bricolo, Jason A. Brodkey, Jacques Brotchi, Jeffrey N. Bruce, Michael Bruneau, Bradley R. Buchbinder, Kim J. Burchiel, Timothy G. Burke, Ali Bydon, Francesco Cacciola, Kevin Cahill, Paolo Cappabianca, Anthony J. Caputy, Francesco Cardinale, Ricardo L. Carrau, Benjamin S. Carson, Bob S. Carter, Giuseppe Casaceli, Laura Castana, Gabriel Castillo, Luigi M. Cavallo, C. Michael Cawley, Aabir Chakraborty, Edward F. Chang, Eric C. Chang, Steven D. Chang, Jens R. Chapman, E. Thomas Chappell, Neeraj Chaudhary, Douglas Chen, James Chen, Linda C. Chen, Boyle C. Cheng, Joshua J. Chern, John H. Chi, Wade W. Chien, E. Antonio Chiocca, Rohan Chitale, Bhupal Chitnavis, Lana D. Christiano, Ray M. Chu, Elisa F. Ciceri, Michelle J. Clarke, Alan Cohen, Annamaria Colao, Geoffrey P. Colby, Massimo Collice, Daniel Condit, Alexander L. Coon, Cassius Vinícius Corrêa Dos Reis, G. Rees Cosgrove, Massimo Cossu, William T. Couldwell, William T. Curry, Guilherme Dabus, Teodoro Forcht Dagi, Giuseppe D'Aliberti, Moise Danielpour, Mark J. Dannenbaum, Ronan M. Dardis, Hormuzdiyar H. Dasenbrock, Reza Dashti, Arthur L. Day, John Diaz Day, Vedran Deletis, Ramiro Del-Valle, Franco DeMonte, Francesco Dimeco, Robert Dodd, Francesco Doglietto, Lutz Dörner, Michael J. Dorsi, Gaby D. Doumit, James M. Drake, Doniel Drazin, Rose Du, Thomas B. Ducker, Hugues Duffau, Bradley S. Duhon, Paula Eboli, Mohamed Samy Elhammady, Pamela Ely, Nancy E. Epstein, Kadir Erkmen, Thomas Errico, Emad N. Eskandar, Clifford J. Eskey, Felice Esposito, Camilo E. Fadul, Gilbert J. Fanciullo, Kyle M. Fargen, Gidon Felsen, Dong Xia Feng, Richard G. Fessler, Aaron G. Filler, John C. Flickinger, John R. Floyd, Kevin T. Foley, Kostas N. Fountas, Howard Francis, James L. Frazier, Kai Frerichs, David M. Frim, Sebastien Froelich, Takanori Fukushima, Philippe Gailloud, Sergio Maria Gaini, Chirag D. Gandhi, Dheeraj Gandhi, Gale Gardner, Paul Gardner, Mark Garrett, Tomás Garzón-Muvdi, Alessandro Gasbarrini, Fred H. Geisler, Joseph J. Gemmete, Massimo Gerosa, Atul Goel, Ziya L. Gokaslan, L. Fernando Gonzalez, C. Rory Goodwin, Takeo Goto, Grahame C. Gould, M. Sean Grady, Andrew W. Grande, Ramesh Grandhi, Alexander L. Green, Jeffrey P. Greenfield, Bradley A. Gross, Rachel Grossman, Mari Groves, Gerardo Guinto, Richard Gullan, Gaurav Gupta, Nalin Gupta, Todd C. Hankinson, Ake Hansasuta, James S. Harrop, Griffith R. Harsh, Alia Hdeib, Stefan Heinze, John Heiss, Dieter Hellwig, Juha Hernesniemi, Roberto C. Heros, Todd Hillman, Jose Hinojosa, Girish K. Hiremath, Brian L. Hoh, L. Nelson Hopkins, Wesley Hsu, Yin C. Hu, Jason H. Huang, Judy Huang, Peter J. Hutchinson, Jonathan A. Hyam, Adriana G. Ioachimescu, Pascal M. Jabbour, Juan Jackson, George I. Jallo, Ivo P. Janecka, Mohsen Javadpour, Andrew Jea, Sunil Jeswani, David H. Jho, Diana H. Jho, Hae-Dong Jho, Bowen Jiang, Tae-Young Jung, M. Yashar S. Kalani, Hideyuki Kano, Silloo B. Kapadia, Michael G. Kaplitt, Christoph Kappus, Eftychia Z. Kapsalaki, Yuval Karmon, Amin B. Kassam, Sudhir Kathuria, Takeshi Kawase, Alexander A. Khalessi, Kathleen Khu, Daniel H. Kim, Matthias Kirsch ., Riku Kivisaari, Angelos G. Kolias, Douglas Kondziolka, Marcus C Korinth, Dietmar Krex, Mark D. Krieger, Kartik G. Krishnan, Ajit A. Krishnaney, Maureen Lacy, Santosh D. Lad, Jose Alberto Landeiro, Frederick F. Lang, Shih-Shan Lang, Françoise LaPierre, Paul S. Larson, Michael T. Lawton, Marco Lee, Martin Lehecka, Allan Levi, Elad I. Levy, Robert E. Lieberson, Michael Lim, Ning Lin, Göran Lind, Bengt Linderoth, Timothy Lindley, Antoine Listrat, Charles Y. Liu, James K. Liu, John C. Liu, Giorgio Lo Russo, Christopher M. Loftus, Russell R. Lonser, Daniel C. Lu, Yi Lu, L. Dade Lunsford, M. Mason Macenski, Jaroslaw Maciaczyk, Joseph R. Madsen, Subu N. Magge, Giulio Maira, Martijn J.A. Malessy, David G. Malone, Allen Maniker, Geoffrey T. Manley, Jotham Manwaring, Mitchell Martineau, Robert L. Martuza, Marlon S. Mathews, Nestoras Mathioudakis, Paul McCormick, Michael W. McDermott, Cameron G. McDougall, H. Maximilian Mehdorn, Vivek A. Mehta, Arnold Menezes, Patrick Mertens, Frederic B. Meyer, Matthew K. Mian, Rajiv Midha, Diego San Millán Ruíz, Jonathan Miller, Neil R. Miller, Zaman Mirzadeh, Ganpati Prasad Mishra, Symeon Missios, James B. Mitchell, Alim Mitha, J. Mocco, Abhay Moghekar, Jacques J. Morcos, Chad J. Morgan, John F. Morrison, Henry Moyle, Carrie R. Muh, Debraj Mukherjee, Arya Nabavi, Michael J. Nanaszko, Dipankar Nandi, Raj Narayan, Sabareesh K. Natarajan, Edgar Nathal, Vikram V. Nayar, Audumbar Shantaram Netalkar, C. Benjamin Newman, Trang Nguyen, Laura B. Ngwenya, Antonio Nicolato, Mika Niemelä, Guido Nikkhah, Anitha Nimmagadda, John K. Niparko, Ajay Niranjan, Richard B. North, José María Núñez, W. Jerry Oakes, Christopher S. Ogilvy, Kenji Ohata, Jeffrey G. Ojemann, Steven Ojemann, David O. Okonkwo, Edward H. Oldfield, Brent O'Neill, Nelson M. Oyesiku, Roberto Pallini, Aditya S. Pandey, Dachling Pang, Kyriakos Papadimitriou, José María Pascual, Aman Patel, Anoop P. Patel, Toral R. Patel, Vincenzo Paterno, Rana Patir, Alexandra R. Paul, Sanjay J. Pawar, Richard Penn, Erlick A.C. Pereira, Mick J. Perez-Cruet, Eric C. Peterson, Mark A. Pichelmann, Joseph M. Piepmeier, Marcus O. Pinsker, Lawrence H. Pitts, Rick J. Placide, Willem Pondaag, Kalmon Post, Matthew B. Potts, Lars Poulsgaard, Gustavo Pradilla, Charles J. Prestigiacomo, Daniel M. Prevedello, Ruth Prieto, Alfredo Quiñones-Hinojosa, Leonidas M. Quintana, Scott Y. Rahimi, Rudy J. Rahme, Rodrigo Ramos-Zúñiga, Nathan J. Ranalli, Shaan M. Raza, Pablo F. Recinos, Violette Renard Recinos, Shrikant Rege, Thomas Reithmeier, Katherine Relyea, Daniel Resnick, Daniele Rigamonti, Philippe Rigoard, Jaakko Rinne, Jon H. Robertson, Shimon Rochkind, Jack P. Rock, Rossana Romani, Guy Rosenthal, Robert H. Rosenwasser, Nathan C. Rowland, James T. Rutka, Samuel Ryu, Francesco Sala, Roberto Salvatori, Kari Sammalkorpi, Nader Sanai, Thomas Santarius, Amar Saxena, Gabriele Schackert, Uta Schick, Thomas A. Schildhauer, Alexandra Schmidek, Henry H. Schmidek, Meic H. Schmidt, Paul Schmitt, Johannes Schramm, Joseph Schwab, Theodore H. Schwartz, Patrick Schweder, Daniel M. Sciubba, R. Michael Scott, Raymond F. Sekula, Patrick Senatus, Amjad Shad, Ali Shaibani, Manish S. Sharma, Rewati Raman Sharma, Sameer A. Sheth, Alexander Y. Shin, Ali Shirzadi, Adnan H. Siddiqui, Roberto Leal Silveira, Nathan E. Simmons, Marc Sindou, Marco Sinisi, Timothy Siu, Edward Smith, Joseph R. Smith, Patricia Smith, Matthew Smyth, Domenico Solari, David Solomon, Adam M. Sonabend, Mark M. Souweidane, Edgardo Spagnuolo, Robert F. Spetzler, Robert J. Spinner, Andreas M. Stark, Philip A. Starr, Ladislau Steiner, Michael P. Steinmetz, Shirley I. Stiver, Prem Subramanian, Michael E. Sughrue, Ian Suk, Daniel Q. Sun, Ulrich Sure, Oszkar Szentirmai, Alexander Taghva, Giuseppe Talamonti, Rafael J. Tamargo, Richard J. Teff, John M. Tew, Nicholas Theodore, Philip V. Theodosopoulos, B. Gregory Thompson, Wuttipong Tirakotai, Stavropoula I. Tjoumakaris, James H. Tonsgard, David Trejo, Michael Trippel, R. Shane Tubbs, Luis M. Tumialan, Andreas Unterberg, Michael S. Vaphiades, T. Brooks Vaughan, Anand Veeravagu, Ana Luisa Velasco, Francisco Velasco, Gregory J. Velat, Angela Verlicchi, Frank D. Vrionis, Michel Wager, M. Christopher Wallace, Gary S. Wand, Benjamin C. Warf, Michael F. Waters, Joseph Watson, Martin H. Weiss, Nirit Weiss, William Welch, J. Kent Werner, Louis A. Whitworth, Christopher Winfree, Timothy F. Witham, Jean-Paul Wolinsky, Judith M. Wong, Shaun Xavier, Bakhtiar Yamini, Claudio Yampolsky, Michael J. Yaremchuk, Reza Yassari, Chun-Po Yen, John Yianni, Alexander K. Yu, Eric L. Zager, Bruno Zanotti, Marco Zenteno, Mehmet Zileli, and Alexandros D. Zouzias

Published
2012
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4. Current treatment options for unruptured intracranial aneurysms

Author

Peng Roc, Chen, Kai, Frerichs, and Robert, Spetzler

Subjects
Cerebral Revascularization, Humans, Intracranial Aneurysm, Neurosurgical Procedures
Abstract

A patient with an unruptured intracranial aneurysm has three options: surgical clip placement, endovascular coil occlusion, and observation. The decision making about management of these lesions should be based on the risk of aneurysm rupture and the risks associated with surgical or endovascular intervention. For patients who require interventions, factors such as aneurysm recurrence rate, its location, surgical or endovascular accessibility, the patient's general medical condition, and the individual's treatment preference should be taken into account to determine the choice of therapies. Currently, a team approach by neurosurgeons and endovascular interventionists is recommended to evaluate each patient and to tailor the best treatment plan.

Published
2005

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