Introduction
: Management of intracranial aneurysms during pregnancy is challenging. The hemodynamic changes during pregnancy increase the risk of intracranial aneurysm rupture. Further, the selection of an appropriate surgical strategy requires a careful review of the potential risks to the mother and fetus. Yet, there is limited data to guide the treatment decisions in this patient population. In this study, we aimed to compare the safety profiles of endovascular coiling (EC) and neurosurgical clipping (NC) in this patient population.
Methods
: Pregnancy‐related hospitalizations with age≥18 years undergoing surgical intervention for intracranial aneurysms were identified from the Nationwide Readmissions Database 2016–2018. Hospitalizations with diagnoses of arteriovenous malformation, cerebral arteritis, and traumatic SAH were excluded. Logistic regression analysis was used to compare outcomes between EC and NC.
Results
: There were 11829044 pregnancy‐related hospitalizations, of which 348 met the study inclusion criteria (mean±SD age: 31.8±5.9). Among 168 patients treated for ruptured aneurysms, 115 (68.5%) underwent EC and 53 (31.5%) underwent NC. Whereas among 180 patients treated for unruptured aneurysms, 140 (77.8%) underwent EC and 40 (22.2%) underwent NC. There were no statistically significant differences in the demographics, clinical presentation, and hospital‐level characteristics between patients undergoing EC versus NC for either ruptured or unruptured aneurysm groups. Among patients with ruptured aneurysms, 11.9% patients had perioperative ischemic stroke, 22.6% patients required mechanical ventilation for >24 hours, 6.5% patients underwent tracheostomy, 6.5% patients had acute kidney injury, 20.2% patients had infectious complications, 4.2% patients underwent gastrostomy tube placement, 30.0% patients had discharge disposition other than to home, 10.1% patients had in‐hospital mortality, and 4.8% patients had non‐elective readmission within 30 days of discharge. These outcomes were comparable between patients with EC and NC, except patients undergoing EC were less likely to develop ischemic stroke [odds ratio (OR): 0.21, 95% confidence interval (CI): 0.05‐0.98] (Figure 1A). None of the 30‐day readmissions were due to procedural complications and a majority (75%) of them were due to pregnancy‐related conditions. Among patients with unruptured aneurysms, 5.6% patients had perioperative ischemic stroke, 5.0% patients required mechanical ventilation for >24 hours, 6.1% patients had infectious complications, 11.1% patients had discharge disposition other than to home, 0.01% patient had in‐hospital mortality, and 0.01% patient had non‐elective readmission within 30 days of discharge. There were no significant differences in these outcomes or in the average length of hospital stay among patients undergoing EC versus NC for unruptured aneurysms (Figure 1B).
Conclusions
: Surgical treatment of intracranial aneurysms during pregnancy is safe with a relatively low rate of early complications. While a majority of patients undergo EC, we found that the safety profiles of NC and EC are largely comparable. Future large studies are needed to further evaluate the advantages and disadvantages of these procedures in detail in this patient population.