Management of Ruptured Intracranial Aneurysms in the Post-International Subarachnoid Aneurysm Trial Era: A Single-Centre Prospective Series

Abstract

Background: Aneurysmal subarachnoid haemorrhage (aSAH) is associated with significant morbidity and mortality. The International Subarachnoid Aneurysm Trial (ISAT) reported reduced morbidity in patients treated with endovascular coiling versus surgical clipping. However, recent studies suggest that there is no significant difference in clinical outcomes. This study examines the outcomes of either technique for treating aSAH during the 15 years post-ISAT at a Canadian quaternary centre. Methods: We reviewed prospectively collected data of patients admitted with aSAH from January 2002 to December 2017. Glasgow Outcome Scale (GOS) was compared at discharge, 6 months and 12 months’ follow-up using univariate and multivariable ordinal logistic regression. Post-operative complications were assessed using binary logistic regression. Results: Two-hundred and eighty-seven patients were treated with coiling and 95 patients with clipping. The mean age of clipped patients was significantly younger, and hypertension was significantly commoner in coiled patients. A greater proportion of coiled aneurysms were located in the posterior circulation. No difference in the odds of having a favourable GOS was seen between patients who were clipped versus coiled at any of follow-up time points on univariate or multivariable analysis. In both treatment groups, patient recovery to independence (GOS 4–5) was seen from discharge to 6 months, but not from 6 to 12 months’ follow-up, without difference between clipping and coiling. Conclusion: These real-world findings suggest clipping remains an effective and important treatment option for patients with aSAH who do not meet ISAT inclusion criteria. The results can assist in clinical decision-making processes and understanding of the natural recovery progression of aSAH.

Clipping versus coiling for aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of prospective studies

“…No significant difference was found for 1-year mortality based on ten studies (RR: 1.07, 95% CI: 0.91-1.26, P = 0.44, Supplemental Fig. 4) [8,15,17,27,32,40,43,56,57,59].…”

“…The representativeness of the cohort was low in 5 studies because they did not include consecutive or random samples [2,16,28,52,60]. Seven studies did not state clearly how they assessed the outcomes [3,12,16,25,46,56,60]. The methodological scores of each cohort are presented in Table 2.…”

“…Six studies reported mortality at discharge [3,8,20,46,56,59]. The pooled result of 1138 patients showed that the mortality did not differ significantly between the two treatment groups at discharge (RR: 0.94, 95% CI: 0.69-1.28, P = 0.69, Supplemental Fig.…”

“…Eight studies with a total of 2167 participants reported the poor outcome at discharge [3,8,20,43,46,52,56,59]. The result indicated that the risk of poor outcome for patients who went through clipping was 1.22 times higher compared with patients who accepted coiling (RR: 1.22, 95% CI: 1.00-1.47, P = 0.04, Supplemental Fig.…”

“…2). Nine studies reported the 1-year outcome of 4050 participants [8,15,27,32,40,43,50,56,59], and results showed that clipping was associated with a 27% greater risk of poor outcome compared with coiling (RR:1.27, 95% CI: 1.16-1.39, P < 0.001, Fig. 3).…”