National trends in treating ruptured and unruptured cerebral aneurysms from 2015 to 2022

Introduction The management strategies for both ruptured and unruptured cerebral aneurysms have been evolving., with microsurgical clipping and endovascular treatment standing as the primary therapeutic modalities. While a shift towards endovascular techniques has been widely reported, there still are unmet need for large‐scale national data reflecting trends and comparative outcomes to understand current clinical practice. We aimed to investigate the national trends in the utilization of microsurgical versus endovascular treatments for ruptured and unruptured cerebral aneurysms and their associated outcomes. Methods Retrospective cohort study using the National Inpatient Sample (NIS) data from October 2015 to December 2022. Patients hospitalized with a primary diagnosis of ruptured or unruptured cerebral aneurysm were identified using International Classification of Diseases, Tenth Revision (ICD‐10‐CM) codes. Corresponding ICD‐10‐PCS procedure codes were used to stratify patients into two treatment cohorts: microsurgical clipping and endovascular treatment. The NIS discharge weights were applied to generate national estimates of the total number of brain aneurysm related hospitalizations. An analysis of treatment trends over the seven‐year period was performed using Mann‐Kendall Test. Results A total of 180,550 weighted hospitalizations for treated cerebral aneurysms were identified. The cohort was stratified into four groups: endovascular treatment for ruptured aneurysms (n=56,625; mean age 57.4 years; 69% female), endovascular treatment for unruptured aneurysms (n=86,215; mean age 59.9 years; 76% female), microsurgical clipping for ruptured aneurysms (n=16,860; mean age 55.2 years; 70% female), and microsurgical clipping for unruptured aneurysms (n=20,850; mean age 57.4 years). Analysis of treatment trends from 2016 to 2022 revealed a significant shift in practice. For both ruptured and unruptured aneurysms, the proportion of cases managed with endovascular treatment significantly increased (p=0.007 and p=0.016, respectively). Regarding total aneurysm treatment, there was significant reduction of unruptured aneurysm treatment during the pandemic period which appears to be recovered in 2022. Conversely, the proportion of cases treated with microsurgical clipping significantly decreased for both ruptured (p=0.007) and unruptured (p=0.016) aneurysms over the study period. Also, the hospitalization for ruptured aneurysm has been stable until 2021 but showed possible downturn in 2022. Conclusion The NIS based analysis demonstrated ongoing shift in the management of cerebral aneurysms toward endovascular management in the United States for both ruptured and unruptured brain aneurysms. Also, unruptured aneurysm treatment was affected by the pandemic. The possible downturn in ruptured aneurysm related hospitalization in 2022 warrant further investigation .