Outcomes of Early Endovascular Versus Surgical Treatment of Ruptured Cerebral Aneurysms

Koivisto, Timo; Vanninen, Ritva; Hurskainen, Heleena; Saari, Tapani; Hernesniemi, Juha; Vapalahti, Matti

doi:10.1161/01.str.31.10.2369

Cited by 365 publications

(261 citation statements)

References 65 publications

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“…Surgical skill level as assessed based on mortality rate The mortality rate for patients with ruptured cerebral aneurysms was 9.6% in the present study, lower than the 14-31% reported in Western countries 7,9,[11][12][13] and lower than the 8.8-48.5% in US studies that investigated relationships between case volume and outcome. 1,18) The mortality rate for patients with unruptured cerebral aneurysm was 0.2% in the present study, also lower than the 1.0-2.6% reported in Western countries.…”

Section: Discussioncontrasting

confidence: 69%

Case Volume Does Not Correlate With Outcome After Cerebral Aneurysm Clipping: A Nationwide Study in Japan

Hattori

Katayama

Abe

2007

Neurol. Med. Chir.(Tokyo)

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The present study analyzed the impact of case volume on outcome after cerebral aneurysm clipping at all 382 core neurosurgical training centers certified by the Japan Neurosurgical Society. A survey requested information on all clipping surgeries for cerebral aneurysms performed during 2003. Among these centers, 369 (96.6%) responded to our request and data satisfactory for analysis were obtained for 11,974 patients. Clinical condition was graded on admission according to the classification of the World Federation of Neurosurgical Societies. Outcomes were evaluated at discharge using the modified Rankin scale. Case volume at centers was divided into three groups based on the number of clippings (º30, 30-50, AE50) performed in 2003. Totals of 7,578 (63.3%) and 4,396 (36.7%) patients underwent clipping for ruptured and unruptured aneurysms, respectively. The mortality rate was 9.6% for patients with ruptured aneurysms, and 0.2% for patients with unruptured aneurysms. No significant correlation was detected between case volume and outcome for either ruptured (Spearman's correlation coefficient ＝ 0.034, p ＝ 0.483) or unruptured aneurysms (Spearman's correlation coefficient ＝ 0.029, p ＝ 0.562). Furthermore, no relationships between case volume and outcome were identified for ruptured aneurysms in each neurological grade or unruptured aneurysms (Kruskal-Wallis test).

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Section: Discussioncontrasting

confidence: 69%

Case Volume Does Not Correlate With Outcome After Cerebral Aneurysm Clipping: A Nationwide Study in Japan

Hattori

Katayama

Abe

2007

Neurol. Med. Chir.(Tokyo)

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“…Three contemporary prospective studies have compared coiling to clipping: the Finnish study, 13 ISAT, 17 and BRAT. 15 Based on their most recent follow-up, none of the 3 studies found a significant difference in rate of independent survival between the 2 treatments.…”

Section: To Clip or To Coil: Is That The Question?mentioning

confidence: 99%

“…13 Their enrollment continued, and altogether 138 patients were randomly assigned to microsurgical clipping (n = 71) or endovascular coiling (n = 67) by the end of 1999. No further follow-up of this trial has been published.…”

Section: To Clip or To Coil: Is That The Question?mentioning

confidence: 99%

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The Barrow Ruptured Aneurysm Trial: 3-year results

Spetzler

McDougall

Albuquerque

et al. 2013

JNS

284

176

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Object The authors report the 3-year results of the Barrow Ruptured Aneurysm Trial (BRAT). The objective of this ongoing randomized trial is to compare the safety and efficacy of microsurgical clip occlusion and endovascular coil embolization for the treatment of acutely ruptured cerebral aneurysms and to compare functional outcomes based on clinical and angiographic data. The 1-year results have been previously reported. Methods Two-hundred thirty-eight patients were assigned to clip occlusion and 233 to coil embolization. There were no anatomical exclusions. Crossovers were allowed based on the treating physician's determination, but primary outcome analysis was based on the initial assignment to treatment modality. Patient outcomes were assessed independently using the modified Rankin Scale (mRS). A poor outcome was defined as an mRS score > 2. At 3 years' follow-up 349 patients who had actually undergone treatment were available for evaluation. Of the 170 patients who had been originally assigned to coiling, 64 (38%) crossed over to clipping, whereas 4 (2%) of 179 patients assigned to surgery crossed over to coiling. Results The risk of a poor outcome in patients assigned to clipping compared with those assigned to coiling (35.8% vs 30%) had decreased from that observed at 1 year and was no longer significant (OR 1.30, 95% CI 0.83–2.04, p = 0.25). In addition, the degree of aneurysm obliteration (p = 0.0001), rate of aneurysm recurrence (p = 0.01), and rate of retreatment (p = 0.01) were significantly better in the group treated with clipping compared with the group treated with coiling. When outcomes were analyzed based on aneurysm location (anterior circulation, n = 339; posterior circulation, n = 69), there was no significant difference in the outcomes of anterior circulation aneurysms between the 2 assigned groups across time points (at discharge, 6 months, 1 year, or 3 years after treatment). The outcomes of posterior circulation aneurysms were significantly better in the coil group than in the clip group after the 1st year of follow-up, and this difference persisted after 3 years of follow-up. However, while aneurysms in the anterior circulation were well matched in their anatomical location between the 2 treatment arms, this was not the case in the posterior circulation where, for example, 18 of 21 posterior inferior cerebellar artery aneurysms were in the clip group. Conclusions Based on mRS scores at 3 years, the outcomes of all patients assigned to coil embolization showed a favorable 5.8% absolute difference compared with outcomes of those assigned to clip occlusion, although this difference did not reach statistical significance (p = 0.25). Patients in the clip group had a significantly higher degree of aneurysm obliteration and a significantly lower rate of recurrence and retreatment. In post hoc analysis examining only anterior circulation aneurysms, no outcome difference between the 2 treatment cohorts was observed at any recorded time point. Clinical trial registration no.: NCT01593267 (ClinicalTrials.gov).

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“…In all other published prospective randomized trials [4][5][6]9 comparing clipping and coiling, equipoise was required before randomization. In contrast, the BRAT was an intent-to-treat trial that entered and randomized all patients with nontraumatic SAH before the source of the hemorrhage was determined.…”

Section: Discussionmentioning

confidence: 99%

Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial

Spetzler¹,

Zabramski²,

McDougall³

et al. 2018

Journal of Neurosurgery

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OBJECTIVEThe Barrow Ruptured Aneurysm Trial (BRAT) is a prospective, randomized trial in which treatment with clipping was compared to treatment with coil embolization. Patients were randomized to treatment on presentation with any nontraumatic subarachnoid hemorrhage (SAH). Because all other randomized trials comparing these 2 types of treatments have been limited to saccular aneurysms, the authors analyzed the current BRAT data for this subgroup of lesions.METHODSThe primary BRAT analysis included all sources of SAH: nonaneurysmal lesions; saccular, blister, fusiform, and dissecting aneurysms; and SAHs from an aneurysm associated with either an arteriovenous malformation or a fistula. In this post hoc review, the outcomes for the subgroup of patients with saccular aneurysms were further analyzed by type of treatment. The extent of aneurysm obliteration was adjudicated by an independent neuroradiologist not involved in treatment.RESULTSOf the 471 patients enrolled in the BRAT, 362 (77%) had an SAH from a saccular aneurysm. Patients with saccular aneurysms were assigned equally to the clipping and the coiling cohorts (181 each). In each cohort, 3 patients died before treatment and 178 were treated. Of the 178 clip-assigned patients with saccular aneurysms, 1 (1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. There was no statistically significant difference in poor outcome (modified Rankin Scale score > 2) between these 2 treatment arms at any recorded time point during 6 years of follow-up. After the initial hospitalization, 1 of 241 (0.4%) clipped saccular aneurysms and 21 of 115 (18%) coiled saccular aneurysms required retreatment (p < 0.001). At the 6-year follow-up, 95% (95/100) of the clipped aneurysms were completely obliterated, compared with 40% (16/40) of the coiled aneurysms (p < 0.001). There was no difference in morbidity between the 2 treatment groups (p = 0.10).CONCLUSIONSIn the subgroup of patients with saccular aneurysms enrolled in the BRAT, there was no significant difference between modified Rankin Scale outcomes at any follow-up time in patients with saccular aneurysms assigned to clipping compared with those assigned to coiling (intent-to-treat analysis). At the 6-year follow-up evaluation, rates of retreatment and complete aneurysm obliteration significantly favored patients who underwent clipping compared with those who underwent coiling.Clinical trial registration no.: NCT01593267 (clinicaltrials.gov)

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Outcomes of Early Endovascular Versus Surgical Treatment of Ruptured Cerebral Aneurysms

Cited by 365 publications

References 65 publications

Case Volume Does Not Correlate With Outcome After Cerebral Aneurysm Clipping: A Nationwide Study in Japan

Case Volume Does Not Correlate With Outcome After Cerebral Aneurysm Clipping: A Nationwide Study in Japan

The Barrow Ruptured Aneurysm Trial: 3-year results

Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial

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