Surgical clipping or endovascular coiling for unruptured intracranial aneurysms: a pragmatic randomised trial

Darsaut, T.E.; Findlay, J. Max; Raymond, Jean; Kotowski, Marc; Roy, Daniel; Weill, Alain; Bojanowski, Michel W.; Chaalala, Chiraz; Iancu, Daniela; Lesiuk, Howard; Sinclair, John; Scholtes, Félix; Martin, Didier; Chow, Michael; O’Kelly, Cian; Wong, John H.; Butcher, Ken; Fox, Allan J.; Arthur, Adam S; Guilbert, F; Tian, Lü; Chagnon, Miguel; Nolet, Suzanne; Gevry, Guylaine

doi:10.1136/jnnp-2016-315433

Cited by 135 publications

(73 citation statements)

References 33 publications

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“…However, the use of some devices comes at the expense of higher thromboembolic events 1. The CURES trial reported 10.1% incidence of new neurological deficits after coiling 25. This risk is comparable to that observed in the control group of our analysis (11%).…”

Section: Discussionsupporting

confidence: 75%

“…Endovascular coiling has become the mainstay treatment of these aneurysms 2. In a recent study, the Collaborative Un-Ruptured Endovascular versus Surgery (CURES) randomized controlled trial compared outcomes following clipping and coiling of unruptured intracranial aneurysms that are deemed treatable by both ways 25. The trial was halted in 2016 for slow accrual, and reported results for the enrolled 136 patients (vs 260 planned).…”

Section: Discussionmentioning

confidence: 99%

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Antiplatelet therapy for prevention of thromboembolic complications in coiling-only procedures for unruptured brain aneurysms

Almekhlafi

Sultan

Kuczynski

et al. 2019

J NeuroIntervent Surg

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Background and purposeThromboembolic events are recognized complications of aneurysm coiling.ObjectiveTo identify any protective effects of antiplatelet therapy use before coiling of unruptured aneurysms.MethodsWe conducted a meta-analysis of clinical studies published up to February 2019. We included studies reporting symptomatic thromboembolic events (defined as clinical stroke or transient ischemic attacks) in patients who received antiplatelet therapy before coiling of unruptured aneurysms using unassisted coiling, balloon assistance, or multiple microcatheters. We excluded ruptured aneurysms and those treated with stent coiling or flow diverters.ResultsWe identified 14 studies (2486 patients). All were single-center studies and four were prospective. In three studies with a control (no treatment) arm, the pooled risk ratio for symptomatic thromboembolic events with versus without antiplatelet therapy was 0.33 (95% CI 0.17 to 0.92, p= 0.035). The cumulative risk of symptomatic thromboembolic events with single antiplatelet agents was 5.0% ‘56/1122’ (95% CI 1.6% to 8.4%, I283.63%), and with dual or multiple agents 2.7% ‘33/1237’ (95% CI 1.0% to 3.0%, I239.9%). The incidence of diffusion lesions was reported in seven studies. It was 50.5% ‘96/190’ (95% CI 7.3% to 93.9%, I294.4%) with single agents compared with 43.9% ‘196/446’ (95% CI 25.9% to 61.9%, I273.4%) with dual or multiple agents.ConclusionPeriprocedural antiplatelet therapy was associated with a low symptomatic thromboembolic event after coiling-only for unruptured aneurysms. However, available evidence is of limited quality with significant heterogeneity, requiring evidence from randomized controlled trials.

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Section: Discussionsupporting

confidence: 75%

Section: Discussionmentioning

confidence: 99%

Antiplatelet therapy for prevention of thromboembolic complications in coiling-only procedures for unruptured brain aneurysms

Almekhlafi

Sultan

Kuczynski

et al. 2019

J NeuroIntervent Surg

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“…Several factors contribute to the rupture risk of IAs, including: smoking, sex, age, ethnicity, co-morbidities, family history and others [7]. In addition there is no clear evidence if microsurgical clipping or endovascular treatment is the better option for the treatment of unruptured IAs [8]. Although endovascular treatment methods changed rapidly over the last decade with several new devices that have been introduced into the market [9][10][11], coil embolization still remains the standard technique for IA embolization.…”

Section: Discussionmentioning

confidence: 99%

SMART coils for intracranial aneurysm repair – a single center experience

et al. 2020

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Background: Due to uniform stiffness of standard platinum coils, dense packing of intracranial aneurysms can be difficult to achieve, since stiffer coils can cause microcatheter prolapse or coil migration. SMART coils have a varying softness along the length of the coils to improve deliverability. We report our initial 2 year experience with the SMART coil system, including direct and follow-up results. Methods: We performed a retrospective study of all patients who underwent coil embolization of an intracranial aneurysm with SMART coils between July 2016 and August 2018 at our institution. We analyzed clinical and angiographic data before and directly after treatment as well as at 6 months follow-up. Results: A total of 49 patients harboring 49 aneurysms were treated; 23 (47%) were ruptured aneurysms. Most aneurysms (57%) were located in the anterior circulation. Median patient age was 55 (31-88), 63% were female. Mean aneurysm size was: neck 3.4 (±1.5), height 6.3 (±2.9) and width 5.2 (±2.3) mm. SMART coils were solely used in 96% of cases. Initial favorable angiographic results were achieved in 45 (92%) of 49 cases, which were stable at 6 months in 26/29 (90%). Thromboembolic complications occurred in 4 (8%) cases without clinical sequelae; microcatheter prolapse occurred in 1 case. No aneurysm rupture or device malfunction was observed. Conclusion: The treatment of ruptured and unruptured intracranial aneurysms with SMART Coils was safe and efficacious in our cohort.

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“…Aside from the use of clips to treat patients with type II and III aneurysms, endovascular coiling embolization is known to be effective for treating patients with these types of aneurysms (29). Use of the coiling technique to treat aneurysms with arteriosclerosis and calcification in the parent artery and aneurysm neck does not significantly change the aneurysm shape (30).…”

Section: Discussionmentioning

confidence: 99%

Clipping treatment of posterior communicating artery aneurysms associated with arteriosclerosis and calcification: A single center study of 136ï¿½cases

Shi

Zhao

et al. 2017

Exp Ther Med

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Abstract. It is widely acknowledged that arteriosclerosis and calcification of the parent artery and aneurysm neck make it difficult to clip posterior communicating artery (PCoA) aneurysms. A total of 136 cases of PCoA aneurysms accompanied by arteriosclerosis and calcification were collected and treated with clipping in the present study. Of the 136 patients, 112 were females (82.4%) and 24 were males (17.6%), with ages ranging from 37 to 76 years (mean age, 60.2 years). Rupture of a PCoA aneurysm was identified in 132 cases (97.1%), and there were 4 cases of unruptured PCoA aneurysms (2.9%). According to the severity of arteriosclerosis and calcification, the aneurysms were divided into type I, II or III. The treatment of type I aneurysms achieved the best curative effect. It is difficult to temporarily occlude type II and III aneurysms during surgery, and temporary occlusion failed in almost 50% of cases. Types II and III were prone to intraoperative aneurysm ruptures. A significantly higher rate of intraoperative aneurysm rupture was seen in type III compared with type II cases. Type II and III cases were more likely to be treated using a fenestrated clip for aneurysm clipping compared with type I cases, and fenestrated clips were used significantly more frequently in type III cases compared with type II cases. Arteriosclerosis and calcification were likely to affect the prognosis of patients, particularly in cases with type III arteriosclerosis and calcification of the parent artery and aneurysm neck. Therefore, the stratification of the arteriosclerosis and calcification of the parent artery and aneurysm neck into types I-III can guide the intraoperative aneurysm clipping strategy, aid in choosing the correct clips, and inform predictions of the occurrence of rupture and hemorrhage, as well as the prognosis for aneurysms.

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Surgical clipping or endovascular coiling for unruptured intracranial aneurysms: a pragmatic randomised trial

Abstract: Surgical clipping or endovascular coiling of UIAs did not show differences in morbidity at 1 year. Trial continuation and additional randomised evidence will be necessary to establish the supposed superior efficacy of clipping.

Cited by 135 publications

References 33 publications

Antiplatelet therapy for prevention of thromboembolic complications in coiling-only procedures for unruptured brain aneurysms

Antiplatelet therapy for prevention of thromboembolic complications in coiling-only procedures for unruptured brain aneurysms

SMART coils for intracranial aneurysm repair – a single center experience

Clipping treatment of posterior communicating artery aneurysms associated with arteriosclerosis and calcification: A single center study of 136ï¿½cases

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