Cranial neurosurgery procedure utilization among patients with acute ischemic stroke

Abstract

Background: Concerns about ready access to neurosurgery after acute ischemic stroke (AIS) may delay or prevent intravenous thrombolysis, thereby leading to poor outcomes. A randomized trial exploring the need for back-up neurosurgery in AIS is unlikely. However, insight may be gained from routine clinical practice. We analyzed the odds and temporal trends of cranial neurosurgery procedure use in patients with AIS using a large U.S. administrative database.

Methods: Data from AIS patients in the Nationwide Inpatient Sample (October 1998 to 2006) who underwent a cranial neurosurgical procedure were analyzed. Multivariate logistic regression with covariate adjustment was used for statistical analysis. Results were stratified by thrombolysis status. Intracerebral hemorrhage (ICH) was used as a key covariate.

Results: Intravenous thrombolysis use increased significantly over time (0.8% to 2.5%; P<.001). Cranial neurosurgical procedures were observed infrequently but increased significantly over time (0.12% to 0.19%; P=.0013), and thrombolysis doubled the odds of a procedure (odds ratio 2.18; 95% confidence interval 1.48-3.21; P<.001). However, thrombolysis only significantly increased the odds of a neurosurgical procedure in the absence of ICH (P<.001).

Conclusions: Thrombolysis should probably not be withheld from eligible AIS patients, even if a concern exists about the lack of readily available neurosurgery, because neurosurgical procedure use is low in routine clinical practice, even after intravenous thrombolysis. Future studies and prospective data might help define the need for standby neurosurgery after AIS and provide further focus on the specific linkage to ICH as a possible mediator variable.

Keywords: Acute ischemic stroke; cerebral infarction; emergency care; guidelines; intracerebral hemorrhage; neurosurgery; thrombolytic therapy.