Improved Cognitive Outcomes With Endovascular Coiling of Ruptured Intracranial Aneurysms

Abstract

Background and Purpose-The International Subarachnoid Aneurysm Trial (ISAT) reported lower rates of death and disability with endovascular versus neurosurgical treatment of ruptured intracranial aneurysms. However, assessment of functional outcome was limited to the modified Rankin Scale, which is known to be insensitive to cognitive function. A neuropsychological substudy (N-ISAT) was therefore done in all recruits from 8 ISAT centers in the United Kingdom. Methods-Detailed neuropsychological assessment was performed at a 12-month follow-up visit. Impairment was defined as performance below the 5th percentile of the study population on at least 2 tests in Ն2 major cognitive domains. Analysis was restricted to patients who were not known to be otherwise disabled according to the modified Rankin Scale (ie, modified Rankin Scale 0 to 2). initially reported the primary clinical outcomes on the modified Rankin Scale (mRS) at 2 months and 1 year after neurosurgical clipping or endovascular coiling as a treatment for ruptured intracranial aneurysms. 1,2 Unfavorable outcomes at 12 months (ie, mRS Grade 3 to 6) were reported in 30.9% of cases randomized to neurosurgery and 23.5% to embolization with a difference in mortality still evident at 5-year follow-up. 3 However, clinical disability and handicap scales such as the mRS are insensitive to poor neuropsychological outcomes, 4,5 and the effect of endovascular versus neurosurgical treatment on cognitive outcomes in patients without physical disability is uncertain. Previous small studies have identified clinically significant neuropsychological impairments with an impact on overall quality of life in patients with an apparently "good" neurological outcome (ie, Glasgow Outcome Scale Grade 1) after subarachnoid hemorrhage (SAH). [5][6][7] The ISAT protocol therefore included a substudy (N-ISAT) in which detailed neuropsychological assessments at 12-month follow-up were performed in all patients randomized from 8 UK centers. We report the rates of cognitive impairment in patients who had no major physical disability (mRS 0 to 2) to Results-Of MethodsThe eligibility, recruitment, and characteristics of ISAT, from which the N-ISAT subsample was drawn, have been reported together with the main trial design and methods. 1 The detailed methods of N-ISAT in terms of organization, training, recruitment, and assessment protocols have also been reported together with an analysis of data quality. 8,9 The study was approved by the Oxford Research Ethics Committee. All patients who had been enrolled in the 8 UK centers participating in N-ISAT and who had survived to 12 months were followed-up as per the main ISAT protocol 1 and were also eligible for face-to-face neuropsychological assessment as part of N-ISAT. Patients were contacted by letter followed by a telephone call initially. Multiple attempts were made to contact nonresponders. 9 Given the uncertainty about the number of cases that would be randomized in the United Kingdom, the pragmatic aim was to study all randomized cas...

Clipping surgery for aneurysmal subarachnoid hemorrhage in patients aged 75 years or older

“…Coil embolization may reduce these symptoms without brain retraction and perforation injury. 24,25 Although the aneurysm size has also been reported to be an important risk factor associated with outcome, 16 the results of the present study indicated no association between aneurysm size and poor outcome. Generally, in direct surgical treatment of large and giant aneurysms, more brain manipulation such as retraction and dissection may be needed to obtain a sufficient operative field, resulting in poor outcome.…”

Higher Incidence of In-Hospital Complications in Patients With Clipped Versus Coiled Ruptured Intracranial Aneurysms

“…Previous studies showed that patients with clipped aneurysms have a higher incidence of neurocognitive deficits and seizures compared with patients with coiled aneurysms. 1,2 However, it remains unknown if patients with clipped aneurysms also have a higher incidence of other in-hospital complications such as pneumonia or myocardial infarction.…”

Dissociation of vasospasm-related morbidity and outcomes in patients with aneurysmal subarachnoid hemorrhage treated with clazosentan: a meta-analysis of randomized controlled trials

“…First, the dichotomous GOSE may be insensitive to clinically important effects of pharmaceutical treatments on outcomes. 1,41 Second, the variability of the doses in the studies may have affected the results. Therefore, the explanation for the dissociation between vasospasm-related morbidity and clinical outcomes may have been unclear, but it is of importance for the design of new clinical trials.…”