C.03 Surgical clipping or endovascular coiling for unruptured intracranial aneurysms: a pragmatic randomized trial

Abstract

Background: Unruptured intracranial aneurysms (UIAs) are treated using endovascular treatment or microsurgical clipping. The safety and efficacy of treatments have not been compared in a randomized trial. Methods: We randomly allocated clipping or coiling to patients with 3-25mm UIAs judged treatable both ways. The primary outcome was treatment failure, defined as: initial failure of aneurysm treatment, intracranial hemorrhage or residual aneurysm on one year imaging. Secondary outcomes included neurological deficits following treatment, hospitalization >5 days, overall morbidity and mortality and angiographic results at one year. Results: 136 patients were enrolled from 2010 through 2016 and 134 patients were treated. The one-year primary outcome, available for 104 patients, was reached in 5/48 (10.4% (4.5%-22.2%)) patients allocated surgical clipping, and 10/56 (17.9% (10.0%-29.8%)) patients allocated endovascular coiling (OR: 0.54 (0.13, 1.90), P=0.40). Morbidity and mortality (mRS>2) at one year occurred in 2/48 (4.2% (1.2%-14.0%)) and 2/56 (3.6% (1.0%-12.1%)) patients allocated clipping and coiling respectively. New neurological deficits (15/65 vs 6/69; OR: 3.12 (1.05, 10.57), P=0.031), and hospitalizations beyond 5 days (30/65 vs 6/69; OR: 8.85 (3.22,28.59), P=0.0001) were more frequent after clipping. Conclusions: Surgical clipping led to greater initial treatment-related morbidity than endovascular coiling. At one year, the superior efficacy of clipping remains unproven and in need of randomized evidence.

Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms—A Global Multicenter Investigation of Perioperative Outcomes

“…By contrast, the rate of residual saccular aneurysms in the endovascularly treated group was 15%. 19 Furthermore, some studies suggest that clipping may be a more cost-effective method of treatment. 20-22 In addition, we confirmed several known patient-specific and aneurysm-specific risk factors.…”

“…The size of the aneurysms treated in our database was comparable with large prospective randomized trials on ruptured and unruptured aneurysms and considered representative. 19,28…”

Interventional Neuroradiology: A Review

“…The PHASES and UIATS scores, developed from the available literature, are commonly used for best management, but they are still imperfect. There is one ongoing RCT of surgery vs. coiling (Canadian Unruptured Endovascular versus Surgery Trial [CURES]), but slow recruitment has delayed formulation of any conclusions 18 . At many centers in the world, 70%-90% of cerebral aneurysms are now treated by EVT 19 .…”