Are Routine Intensive Care Admissions Needed after Endovascular Treatment of Unruptured Aneurysms?

Discussion

We have prospectively evaluated a policy of selective ICU admission in a consecutive, unselected population of patients undergoing endovascular treatment of unruptured intracranial aneurysms. Since adoption of this policy, >60% of patients were admitted to the floor, which has resulted in reduced utilization of specialized hospital resources. Only 1 patient required a change of admission status because of a deficit noted on admission to the neurosurgical ward. This event was promptly recognized, and the patient was treated without any untoward neurologic sequelae. Our study suggests that a large number of patients who undergo elective endovascular treatment of unruptured intracranial aneurysms do not need the specialized and intensive monitoring provided in an ICU environment. There were no complications seen among patients in the ICU admitted for aneurysmal morphology or investigational device reasons, perhaps indicating a more aggressive policy of admission to the floor is possible.

As shown by other authors, both thromboembolic and hemorrhagic complications are not infrequent during endovascular procedures for intracranial aneurysms but can be promptly recognized and treated in the angiographic suite, thus resulting in a low rate of permanent co-morbidity and mortality.^3,4 In our series, most complications were evident during the procedure or on awakening from anesthesia.

There is limited information about the need and indications for ICU admission in patients undergoing elective endovascular procedures. Studies on neurosurgical patients after craniotomy have suggested that ICU care after craniotomy may not be necessary.^5,6 Zimmerman et al⁷ conducted a multicenter analysis of 3000 patients admitted to ICU care for neurosurgical diseases and found that among patients who were only observed in the ICU, <10% were likely to need any ICU treatments. Their analysis highlighted the need for comprehensive admission guidelines to the ICU. Beauregard and Friedmann⁶ reported that 2 of 132 patients required ICU admission from the floor after craniotomy. Similarly, Bui et al⁵ reported 10 response calls among 343 elective craniotomy patients, none of which resulted in ICU transfer. Clearly, patients with some neurologic interventions can be safely observed in a general ward, and the safety of this practice among patients undergoing elective aneurysm treatment is shown for the first time in this study.

Our study has limitations. It is a single-center study, we did not include a cost-saving analysis, and the triaging criteria that we used have not been validated and were only carried out by the senior author. Admission of the selected patients to the ICU may have avoided a complication, and this is not accounted for in our analysis. However, none of the complications that could have been prevented by ICU admission (such as prompt recognition of new ischemic symptoms, hemodynamic instability in a patient with large access hematoma, or cardio-respiratory issues) occurred in our cohort of patients admitted to the ICU who were stable in the angiography suite and did not have intraprocedural events. It can also be argued that the rate of transfer to the ICU after floor admission would have been higher had all of the patients been admitted directly to a regular ward. However, as previously mentioned, there were no complications observed in the patients admitted to the ICU who were stable after awakening from anesthesia and who had had a “straightforward” procedure. Moreover, the paradigm presented may not be applicable in every center because patients are admitted to a regular floor or to the ICU, depending on the level of comfort with floor care, which is variable from center to center.