Clinical Research
Integrating endovascular techniques into established open neurosurgery practice: a temporal analysis of treatment evolution in a dual-trained neurosurgical unit
Integración de técnicas endovasculares en la práctica de la neurocirugía abierta: análisis temporal de la evolución del tratamiento en una unidad de neurocirugía vascular dual
Ignacio Arrese
, Sergio García-García, Santiago Cepeda, Rosario Sarabia
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Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
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The navy blue line indicates the proportion of OPEN procedures, while the crimson line represents the ENDO procedures.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ignacio Arrese, Sergio García-García, Santiago Cepeda, Rosario Sarabia" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Ignacio" "apellidos" => "Arrese" ] 1 => array:2 [ "nombre" => "Sergio" "apellidos" => "García-García" ] 2 => array:2 [ "nombre" => "Santiago" "apellidos" => "Cepeda" ] 3 => array:2 [ "nombre" => "Rosario" "apellidos" => "Sarabia" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1130147324000745" "doi" => "10.1016/j.neucir.2024.06.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147324000745?idApp=UINPBA00004B" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849624000352?idApp=UINPBA00004B" "url" => "/25298496/unassign/S2529849624000352/v1_202407110420/en/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1130147324000757" "issn" => "11301473" "doi" => "10.1016/j.neucir.2024.06.004" "estado" => "S300" "fechaPublicacion" => "2024-11-01" "aid" => "618" "copyright" => "Sociedad Española de Neurocirugía" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Neurocirugia. 2024;35:289-98" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Investigación clínica</span>" "titulo" => "Aneurismas intracraneales no rotos tratados con microcirugía: análisis de resultados clínicos y radiológicos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "289" "paginaFinal" => "298" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Microsurgical clipping of unruptured intracranial aneurysms: clinical and radiological outcomes" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1907 "Ancho" => 1350 "Tamanyo" => 423284 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A y B) Técnica de abordaje minipterional con separación roma de las fibras del músculo temporal. C y D) Técnicas más empleadas de clipaje de aneurismas de ACM mediante minicraneotomía para evitar las «orejas de perro», siguiendo el concepto de <span class="elsevierStyleItalic">ideal closure line</span>. E y F) Ejemplos de clipaje de aneurismas múltiples mediante minicraneotomía: E) clipaje de aneurisma de AcoA y ACM mediante abordaje lateral supraorbitario derecho, F) clipaje de aneurisma de AchoA derecha, A1 izquierda y top de la basilar mediante abordaje minipterional derecho.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Silvia Vázquez Sufuentes, Loreto Esteban Estallo, Jesús Moles Herbera, Luis Manuel González Martínez, Jouke Sieds van Popta, Juan Casado Pellejero" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Silvia" "apellidos" => "Vázquez Sufuentes" ] 1 => array:2 [ "nombre" => "Loreto" "apellidos" => "Esteban Estallo" ] 2 => array:2 [ "nombre" => "Jesús" "apellidos" => "Moles Herbera" ] 3 => array:2 [ "nombre" => "Luis Manuel" "apellidos" => "González Martínez" ] 4 => array:2 [ "nombre" => "Jouke" "apellidos" => "Sieds van Popta" ] 5 => array:2 [ "nombre" => "Juan" "apellidos" => "Casado Pellejero" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529849624000467" "doi" => "10.1016/j.neucie.2024.07.007" "estado" => "S200" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849624000467?idApp=UINPBA00004B" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147324000757?idApp=UINPBA00004B" "url" => "/11301473/0000003500000006/v1_202411050451/S1130147324000757/v1_202411050451/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical Research</span>" "titulo" => "Integrating endovascular techniques into established open neurosurgery practice: a temporal analysis of treatment evolution in a dual-trained neurosurgical unit" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "281" "paginaFinal" => "288" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ignacio Arrese, Sergio García-García, Santiago Cepeda, Rosario Sarabia" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Ignacio" "apellidos" => "Arrese" "email" => array:1 [ 0 => "iarrese14@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Sergio" "apellidos" => "García-García" ] 2 => array:2 [ "nombre" => "Santiago" "apellidos" => "Cepeda" ] 3 => array:2 [ "nombre" => "Rosario" "apellidos" => "Sarabia" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Integración de técnicas endovasculares en la práctica de la neurocirugía abierta: análisis temporal de la evolución del tratamiento en una unidad de neurocirugía vascular dual" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1541 "Ancho" => 2508 "Tamanyo" => 200545 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This graph displays the annual predicted probability of achieving a 'Good Outcome' following neurosurgical intervention, differentiated by treatment type ON (OPEN) and EN (ENDO). Probabilities are expressed as percentages to facilitate interpretation. The blue line represents the OPEN treatment approach, and the orange line depicts the ENDO approach. It should be noted that the observed trends over time and between treatment types did not reach statistical significance according to the logistic regression analysis (p > 0.05 for interaction terms).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Several studies have highlighted the efficacy of a policy where aneurysms are treated by Dual-trained Neurovascular surgeons (DTNS) skilled in both endovascular neurosurgery (EN) and open neurosurgery (ON) techniques.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> Despite the trend in some countries for neurosurgeons to employ both these techniques in their treatment of intracranial aneurysms (ICAs), this is not commonly observed in Europe. Political barriers have limited the involvement of neurosurgeons in endovascular procedures.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> As a result, few neurosurgeons are trained in endovascular techniques, and an even smaller number are including in their armamentarium both open and endovascular procedures for ICAs treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">As a case in point, our Unit stands as the sole facility where all neurovascular procedures (ON or EN) are treated by the same team of neurosurgeons within the Spanish public health system. Established 12 years ago, this Unit was envisioned to promote such a holistic approach. The first two neurosurgeons were primarily from the ON domain. Following a comprehensive training phase, aided by several interventional neuroradiologists, the so-called "dual policy” was adopted.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In a study by Jiang et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which examined the treatment preferences of DTNS during their initial 24 months of practice, it was observed that most ICAs were treated with EN. Our objective is to analyze the time trend of the introduction of endovascular techniques in an originally ON unit and the impact of the combination of both techniques on patient outcome.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Data extraction</span><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted a retrospective cohort study on rICAs managed in our Unit between October 2012 and June 2023. All procedures were carried out or supervised by senior neurosurgeons (IA, RS).</p><p id="par0025" class="elsevierStylePara elsevierViewall">All cases from the subarachnoid hemorrhage (SAH) database of our Unit of Vascular Neurosurgery were thoroughly examined.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Exclusion Criteria: Non-aneurysmatic SAH; non-sacular rICAs (i.e., fusiform or blister ICAs); patients considered unsuitable for any treatment because of bad clinical status; patients without a recorded 6-month follow-up. In instances where a patient presented with an aneurysmatic SAH but had multiple ICAs, Only the aneurysm suspected of causing the SAH was assessed.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Demographic data, rICAs location, morphological features of the rICAs, modified World Federation Neurosurgical Societies Scale (mWFNS)<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> dichotomized in good grade<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> and poor Grade,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> Modified Fisher Scale (mFS)<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> dichotomized in<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> and<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> scores before treatment, duration from SAH symptom onset to treatment, technique used for rICAs closure, and acute phase events (e.g., ventriculomegaly managed with drainage, sonographic and angiographic vasospasm, delayed cerebral ischemia (DCI), seizures) were all collected.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The primary outcome metric was the Modified Rankin Scale (mRS)<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> at 6 months post-rupture, divided into good outcome (scores 0–3) and poor outcome (scores 4–6).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Management</span><p id="par0045" class="elsevierStylePara elsevierViewall">All patients underwent an angio-CT scan prior to determining treatment approach. If the DTNS team considered ON as optimal, the patient proceeded to the operating room. In cases considered primarily for EN or uncertain treatment cases, the patient was directed to the angiography suite. After diagnostic angiography, if EN was deemed appropriate, it was pursued. Alternatively, if ON was the chosen strategy, the patient was transferred to the operating room.</p><p id="par0050" class="elsevierStylePara elsevierViewall">For ON interventions, a craniotomy was performed based on the aneurysm's location and attributes. Universal use of microsurgical techniques was observed, with intraoperative sonography and indocyanine green angiography employed to confirm aneurysm occlusion and post-clipping arterial patency. Systematic opening of the lamina terminalis, available cisterns, and fluid clearance were undertaken.</p><p id="par0055" class="elsevierStylePara elsevierViewall">When EN was considered best, diagnostic angiography, inclusive of 3D sequences, was utilized to study the aneurysm's architecture and neighboring arterial branches. Due to our concerns about double anti-aggregation during the acute phase of SAH, stent-assisted coiling or flow diverters were not used for acutely rICAs. Aneurysm treatment involved single coiling, dual catheter technique, or balloon-assisted coiling.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Regardless of the treatment modality, post-operative care protocols remained uniform, with patients being admitted to the Neurocritical Care Unit. Those with a positive pre-surgical status were targeted for prompt extubation post-intervention. For cases with challenging clinical situations, ICP and PtiO2 monitoring were implemented. Transcranial ultrasound doppler was routinely performed. Upon detection of vasospasm either clinically or sonographically, perfusion CT scan was indicated, with initial hypertension management followed by endovascular treatment if necessary.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">In the descriptive analysis, we used percentages and proportions to present categorical variables. The Shapiro-Wilk test determined the distribution of continuous data. For variables with a normal distribution, we reported means and standard deviations (SDs). For non-normally distributed variables, we presented the median and range.</p><p id="par0070" class="elsevierStylePara elsevierViewall">To compare the means of continuous variables between two groups defined by a dichotomous variable, we used an independent samples t-test for normally distributed data. For data not following a normal distribution, the Mann–Whitney U test was employed. When comparing dichotomous variables against either dichotomous or ordinal variables, the Chi-squared test was utilized. For multivariable analyses, logistic regression assessed relationships between independent and dependent variables.</p><p id="par0075" class="elsevierStylePara elsevierViewall">We analyzed the evolution of treatments (ON vs. EN) and their outcomes over time using the Chi-squared test. Logistic regression helped identify factors influencing treatment selection. A logistic regression model was applied to determine trends in the proportion of favourable outcomes annually. To evaluate which factors influenced the evolution of treatment choices and outcomes through multivariable analysis, we implemented a mixed-effects time series model.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> This model is particularly advantageous for handling data that includes multiple levels of grouping and for adjusting random effects, providing a robust way to deal with the hierarchical structure of clinical data. A tree model was created to make a more intuitive visualization of the evolution of the treatments.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Statistical analyses were performed using Python 3.11.6 and its associated libraries, and the tree model was constructed using Orange 3.36.1 software (Bioinformatics Laboratory at the University of Ljubljana, Slovenia).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical considerations</span><p id="par0085" class="elsevierStylePara elsevierViewall">We obtained the consent of the patients or their representatives for the use of their data. All data were anonymized to protect patient identity and privacy. The research was carried out without conflict of interests. It received approval from the Institutional Review Board of our hospital.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">Demographic characteristics of the patients, location and morphology of the rICAs, and outcome are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">In our univariate analysis, sex displayed a statistically significant association with 6-month postoperative outcomes (4.38, p < 0.05). The mFS and the mWFNS revealed strong associations with 6-month outcomes, Chi-square statistics of 37.72 and 35.02, respectively, both yielding p-values of <0.00001. Contrarily, the surgical treatment, ON vs EN, did not demonstrate a significant effect on outcomes (0.8960, p-value: >0.85). In the adjusted multivariate logistic regression, both mFS -1.58 (p: 0.011) and mWFNS −0.87 (p < 0.001) sustained their statistical significance, highlighting their substantial and independent effects on 6-month outcomes following neurosurgical interventions. The variable sex lost its statistical significance in the multivariate model 0.31 (p = 0.53).</p><p id="par0100" class="elsevierStylePara elsevierViewall">In the analysis focused on neurosurgical treatment selection, rICAs location emerged as a statistically significant: 29.58( p = 0.0001), suggesting its influence on the decision-making process for choosing between ON and EN approaches. This significant association highlights the potential role of lesion location in guiding surgical strategy in neurosurgical practice.</p><p id="par0105" class="elsevierStylePara elsevierViewall">We have analyzed the evolution of the treatments ON vs EN over the time (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The longitudinal analysis of neurosurgical treatment modalities revealed a statistically significant temporal trend in the selection of EN (Chi-square statistic: 26.32 (p = 0.0058). We conducted a mixed-effects time series model for multivariable analysis The results showed that while patient or rICAs characteristics did not significantly predict the treatment choice, the year of treatment was statistically significant 0.16 (p = 0.002).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">With regard to the evolution of the outcome during the years we applied a logistic regression model to assess the trend in the proportion of good outcomes by year. The data suggests a 2.12% increase in good outcomes each year. However, the statistical analysis does not confirm this trend to be significant, with a p = 0.182. The logistic regression analysis with interaction terms aimed to assess the impact of time and treatment type on patient outcomes did not yield statistically significant results. Specifically, the coefficient for the year was 0.0226 (p = 0.723), for the treatment type was 166.249 (p = 0.4), and for the interaction term between the year and treatment type was 0.082 (p = 0.4). These findings suggest there is no statistical evidence within the available data to conclude that the evolution of treatment modalities over time has influenced the likelihood of a good outcome vs poor outcome in the context of neurosurgical interventions (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The choice of treatment for rICAs (ON vs EN) is strongly influenced by their location. However, the longitudinal trends in the selection of treatment based on rICAs location do not demonstrate statistical significance. So, a tree model was created to make more intuitive the analysis of this non significative evolution. The area under curve (AUC) of that model was 0.71 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The influence of annual variations on the tree model demonstrates an erratic pattern, particularly affecting the 'location' variable of ICAs. This erraticism may contribute to the absence of a statistically significant temporal trend in the comparative efficacy of ON versus EN treatments. It suggests that the 'location' of ICAs remains the most adaptable variable, interpreted flexibly by DTNS, who often consider both treatment options viable.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">Our experience adds up to the current body of evidence demonstrating an increase over time in the implementation of endovascular techniques even in the context of DTNS and without a negative impact in patients’ outcomes.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The prevalence of open neurosurgery remains in our unit compared to hospitals where interventional neuroradiologists perform EN and neurosurgeons solely perform ON.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> A pertinent factor in this context may be that both senior neurosurgeons had exclusively practiced ON before transitioning to endovascular therapy. Based on our observations, simultaneous training in both ON and EN may foster a greater propensity to adopt endovascular strategies, attributed to the accelerated development of procedural competence.</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Evolution of Open vs. Endovascular Treatments</span><p id="par0130" class="elsevierStylePara elsevierViewall">Our analysis indicates a significant rise in the proportion of endovascular interventions for rICAs over time. However, multivariate analysis has not identified any particular variable responsible for this trend. Therefore, we can only offer subjective interpretations based on our experiences.</p><p id="par0135" class="elsevierStylePara elsevierViewall">One potential factor contributing to the increasing reliance on endovascular treatments for ruptured ICAs could be the introduction of neurosurgeons without prior endovascular experience to our team. The training requirements for these newcomers might incline the team towards EN in ambiguous cases where either technique could be applicable in order to increase skills and confidence in the EN techniques. The consistency in selecting techniques for certain aneurysm locations over time, as opposed to the variable approach initially observed, lends credence to this hypothesis.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Another plausible explanation, as suggested by the treatment evolution graph, is the impact of the COVID-19 pandemic (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Reduced operating room availability during this period may have catalyzed a shift towards EN, subsequently becoming a persisting practice.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Influence on outcomes</span><p id="par0145" class="elsevierStylePara elsevierViewall">Our study reveals that the increased utilization of endovascular techniques has not altered the functional prognosis for patients with SAH, nor has it impacted the final treatment outcomes. This suggests that the post-ISAT advocacy for preferring EN when both options are viable should not be applied rigidly. Instead, a more individualized technique selection approach, considering each case's unique aspects, may be more beneficial. Our study encompasses an unselected series of all cases presenting to the hospital,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> revealing that patient and aneurysmal characteristics markedly differ from those in the ISAT. This variation highlights the necessity of an individualized treatment approach that extends beyond the post-ISAT recommendations.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Location a treatment</span><p id="par0150" class="elsevierStylePara elsevierViewall">Location emerges as the paramount factor in selecting the optimal treatment between ON and EN. While MCA rICAs are almost invariably treated with ON, aneurysms in the posterior circulation and paraclinoid regions have predominantly been addressed with EN. rICAs in the anterior circulation, excluding paraclinoid and MCA aneurysms, display greater treatment flexibility, with management decisions tailored to the specific case. These findings concur with prior research indicating a predilection for one treatment over the other based on aneurysm location.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14–17</span></a> This insight underscores the significance of employing units composed of DTNS. A singular treatment approach may overshadow the other, potentially compromising a comprehensive evaluation in marginal cases.</p><p id="par0155" class="elsevierStylePara elsevierViewall">While multivariate and mixed-effects analysis suggests that the location of the aneurysm significantly influences treatment choice, it is critical to recognize that other factors not included in the model, such as the relationship of perforators and branches arising from the aneurysm neck, may also be critical in treatment selection. These factors should be considered by DTNS when evaluating each case, allowing for more precise and tailored treatment selection based on the specific characteristics of the aneurysm.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Dual approach</span><p id="par0160" class="elsevierStylePara elsevierViewall">Contrary to the practice in most European centres, where radiologists predominantly perform these procedures, our stance advocates or the benefits that DTNS can bring to the management of rICAs.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5,7,8</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,18</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In the context of SAH, sealing the rICAs constitutes only one aspect of patient care.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a> Neurosurgical treatment encompasses various invasive techniques for managing neurocritical patients, often necessitating active involvement in Intensive Care Units. This comprehensive involvement facilitates a more holistic approach to patient care than if the practitioner's role were limited to ICA closure. Furthermore, a robust foundation in vascular neurosurgery, supplemented by extensive endovascular training, equips practitioners with a thorough understanding of cerebrovascular pathologies and their treatment modalities. In our experience, the application of both techniques not only maintains but enhances proficiency in each.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Additionally, possessing expertise in both methods enables neurosurgeons to tailor the treatment approach to the patient's specific circumstances and the aneurysm's characteristics. While the term 'multidisciplinarity' is ubiquitously cited in studies and guidelines, treatment choice variability among centres in our region persists, influenced by the specialty weight of the service most involved in aneurysm therapy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">The economic implications warrant attention. The versatility of DTNS reduces the demand for multiple specialists managing the same condition, which is particularly salient in lower-volume settings like ours (20–25 SAH cases annually).</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Limitations</span><p id="par0180" class="elsevierStylePara elsevierViewall">This study is subject to certain limitations due to its retrospective design, which may introduce indication and selection biases stemming from non-randomized treatment allocation. Additionally, being a single-centre analysis, the extrapolation of our conclusions to other institutions with different characteristics must be approached with caution. Lastly, the small case number restricts the statistical power required to discern the impact of specific variables.</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Our findings indicate that the implementation of endovascular and open surgery techniques by DTNS, and the temporal shift toward a preference for endovascular treatment, were not associated with an improvement in patient outcomes. This observation underscores the importance of comprehensive training in endovascular techniques within neurosurgical residency, highlighting the complexity of managing aneurysmal SAH and the necessity for proficiency in both neurocritical and neurosurgical care of this severe disease.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Sources of funding</span><p id="par0190" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Disclosures</span><p id="par0195" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres2292603" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objetive" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1905252" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2292604" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1905251" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Data extraction" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Management" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Ethical considerations" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:3 [ "identificador" => "sec0040" "titulo" => "Discussion" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Evolution of Open vs. Endovascular Treatments" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Influence on outcomes" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Location a treatment" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Dual approach" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Limitations" ] ] ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Sources of funding" ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Disclosures" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-01-09" "fechaAceptado" => "2024-06-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1905252" "palabras" => array:5 [ 0 => "Intracranial aneurysm" 1 => "Subarachnoid haemorrhage" 2 => "Dual-trained neurosurgeons" 3 => "Clipping" 4 => "Coiling" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1905251" "palabras" => array:5 [ 0 => "Aneurismas intracraneales" 1 => "Hemorragia subaracnoidea" 2 => "Neurocirujanos entrenamiento dual" 3 => "Clipaje" 4 => "Embolización" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetive</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In Europe, units with Dual-trained Neurovascular Surgeons (DTNS) skilled in both open neurosurgery (ON) and endovascular neurosurgery (EN) are scarce. For instance, in Spain, our unit is unique within the public health system, where all neurovascular procedures are carried out by DTNS. Our study aims to evaluate the evolution in treating ruptured intracranial aneurysms (rICAs) and assess the impact of this evolution on clinical outcomes.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A retrospective cohort study was performed on rICAs treated in our unit from October 2012 to June 2023. We reviewed clinical and radiological data to analyze the evolution of ON and EN over time, as well as their impact on patient outcomes. Univariate, multivariate, and mixed-effects models were utilized to discern temporal changes.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The modified Fisher Scale (mFS) and the modified World Federation of Neurological Surgeons scale (mWFNS) showed strong correlation with the outcome at 6 months outcomes, both with p < 0.00001. However, the surgical intervention method, ON versus EN, did not significantly affect outcomes (p > 0.85). In adjusted multivariate logistic regression, mFS (−1.579, p: 0.011) and mWFNS (−0.872, p < 0.001) maintained their significance. rICAs location was significant when comparing ON to EN p = 0.0001. A significant temporal trend favored the selection of EN p = 0.0058). Mixed-effects time series modeling indicated that while patient characteristics and rICA specifics did not predict treatment choice, the year of treatment was significantly correlated (0.161, p = 0.002). Logistic regression with interaction terms for time and treatment type did not produce significant results.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Our findings suggest that despite an increased adoption of EN techniques, there has been no change in patient outcomes. Even with the rise of EN, our unit continues to perform ON for a higher proportion of rICAs than most national hospitals. We propose that a “dual approach” offers advantages in a patient individualized treatment decision protocol in the European context.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objetive" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En Europa, las unidades con Cirujanos Neurovasculares de Doble Formación (DTNS) capacitados tanto en neurocirugía abierta (ON) como en neurocirugía endovascular (EN) son escasas. Por ejemplo, en España, nuestra unidad es única dentro del sistema público de salud, donde todos los procedimientos neurovasculares son realizados por DTNS. Nuestro estudio tiene como objetivo evaluar la evolución en el tratamiento de aneurismas intracraneales rotos (rICAs) y evaluar el impacto de esta evolución en los resultados clínicos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se ha realizado un estudio de cohorte retrospectivo sobre rICAs tratados en nuestra unidad desde octubre de 2012 hasta junio de 2023. Revisamos datos clínicos y radiológicos para analizar la evolución de ON y EN a lo largo del tiempo, así como su impacto en los resultados de los pacientes. Se utilizaron modelos univariados, multivariados y de efectos mixtos para discernir cambios temporales.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La Escala Fisher modificada (mFS) y la Escala de la Federación Mundial de Cirujanos Neurológicos modificada (mWFNS) mostraron una fuerte correlación con el resultado a los 6 meses, ambos con p < 0.00001. Sin embargo, el método de intervención quirúrgica, ON versus EN, no afectó significativamente los resultados (p > 0.85). En la regresión logística multivariada ajustada, mFS (−1.579, p: 0.011) y mWFNS (−0.872, p < 0.001) mantuvieron su significancia. La ubicación de los rICAs fue significativa al comparar ON con EN (p = 0.0001). Se observó una tendencia temporal significativa a favor de la selección de EN (p = 0.0058). La modelización de series temporales de efectos mixtos indicó que, mientras las características de los pacientes y los detalles específicos de los rICA no predecían la elección del tratamiento, el año del tratamiento estaba significativamente correlacionado (0.161, p = 0.002). La regresión logística con términos de interacción para el tiempo y el tipo de tratamiento no produjo resultados significativos.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Nuestros hallazgos sugieren que, a pesar de una adopción creciente de técnicas EN, no ha habido un cambio en los resultados de los pacientes. Incluso con el auge de EN, nuestra unidad continúa realizando ON para una mayor proporción de rICAs que la mayoría de los hospitales nacionales. Proponemos que un "enfoque dual" ofrece ventajas en un protocolo de decisión de tratamiento individualizado para pacientes en el contexto europeo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1526 "Ancho" => 2508 "Tamanyo" => 226263 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The graph illustrates the evolution of treatment modality preferences over time, as represented by the rolling average proportion of EN (ENDO) and ON (OPEN) neurosurgical procedures. The navy blue line indicates the proportion of OPEN procedures, while the crimson line represents the ENDO procedures.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1541 "Ancho" => 2508 "Tamanyo" => 200545 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This graph displays the annual predicted probability of achieving a 'Good Outcome' following neurosurgical intervention, differentiated by treatment type ON (OPEN) and EN (ENDO). Probabilities are expressed as percentages to facilitate interpretation. The blue line represents the OPEN treatment approach, and the orange line depicts the ENDO approach. It should be noted that the observed trends over time and between treatment types did not reach statistical significance according to the logistic regression analysis (p > 0.05 for interaction terms).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1315 "Ancho" => 3508 "Tamanyo" => 274919 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The decision tree model indicates a consistent preferential trend towards endovascular techniques for aneurysms located in the posterior circulation and paraclinoid regions. Conversely, middle cerebral artery (MCA) aneurysms have been predominantly managed with open surgical approaches. Aneurysms in other regions of the anterior circulation exhibit an erratic inclination towards EN over time.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Demographic characteristics</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Age (Mean ± SD)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56.88 ± 11.66</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sex (M/F)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60/76</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypertension (%)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.79</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Smoking (%)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.26</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes (%)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.76</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alcoholism (%)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.89</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total Cases</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">136</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pretreatment</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>mFS (1,2)/(3,4)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21/115</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Good grade/Poor Grade</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">89/47</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICs location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ENDO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">OPEN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TOTAL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ACA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ACoA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MCA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PCoA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paraclinoid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post Circ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Morphologic ICs</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diameter (Median-Range)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.6 (2.0−48.0)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neck (Median and Range)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.0 (1.0−12.0)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High (Median and Range)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.7 (2.0−48.0)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Width (Median and Range)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.86 (3.0−37.0)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DN-ratio (Median and Range)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.25 (0.66−8.5)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aspect Ratio (Median and Range)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.0 (0.33−8.0)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Outcome</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mortality (%)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.41</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Favourable Outcome 6 m (%)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60.74</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Poor Outcome 6 m (%)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.26</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3715517.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Overview of patient demographics, pretreatment conditions, aneurysm locations, morphological features, and 6-month post-treatment outcomes.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microsurgical and endovascular treatment of un-ruptured cerebral aneurysms by European hybrid neurosurgeons to balance surgical skills and medical staff management" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.R. 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