Surgical and endovascular treatment for ruptured anterior circulation cerebral aneurysms: A comparison of outcomes – A single centre study from Taiwan

Global Disparities in the Presentation and Management of Aneurysmal Subarachnoid Hemorrhage: A Review and Analysis

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality rates. There is a significant gap in the literature describing global disparities in demographics, management, and outcomes among patients with aSAH. We aimed to conduct a systematic review and meta-analysis to assess global disparities in aSAH presentation and management.

METHODS

PubMed and Embase databases were queried from earliest records to November 2022 for aSAH literature. Presentation, demographics, comorbidities, treatment methods, and outcomes data were collected. Articles that did not report aSAH-specific patient management and outcomes were excluded. Pooled weighted prevalence rates were calculated. Random effects model rates were reported.

RESULTS

After screening, 33 articles representing 10,553 patients were included. The prevalence of Fisher grade 3 or 4 aSAH in high- and lower-income countries (HIC and LIC), respectively, was 79.8% (P < 0.01) and 84.1 (P < 0.01). Prevalence of male aSAH patients in HIC and LIC, respectively, was 35.8% (P < 0.01) and 45.0% (P < 0.01). Prevalence of treatment in aSAH patients was 99.5% (P < 0.01) and 99.4% (P = 0.16) in HIC and LIC, respectively. In HIC, 35% (P < 0.01) of aneurysms in aSAH patients were treated with coiling. No LIC reported coiling for aSAH treatment; LIC only reported rates of surgical clipping, with a total prevalence of 92.4% (P < 0.01) versus 65.6% (P < 0.01) in HIC.

CONCLUSION

In this analysis, we found similar rates of high-grade SAH hemorrhages in HIC and LIC but a lack of endovascular coil embolization treatments reported in LIC. Additional research and discussion are needed to identify reasons for treatment disparities and intervenable societal factors to improve aSAH outcomes worldwide.

Neurosurgical clipping versus endovascular coiling for patients with ruptured anterior circulation aneurysms: A systematic review and meta-analysis

To compare the safety and efficacy of clipping and coiling in patients with ruptured anterior circulation aneurysms. A systematic search of four databases (PubMed, Web of Science, Cochrane Library, and Embase) was conducted to identify comparative articles on endovascular coiling and surgical clipping in patients with ruptured anterior circulation aneurysms. Meta-analyses were conducted using random-effects models. Nineteen studies, including 1983 patients, were included. The meta-analysis showed that neurosurgical clipping was associated with a lower incidence of retreatment (OR:0.28, 95% CI (0.11, 0.70), P = 0.006) than endovascular coiling, which seemed to be a result of incomplete occlusion (OR:0.22, 95% CI (0.11, 0.45), P < 0.001). Neurosurgical clipping was associated with lower mortality (OR:0.45, 95% CI (0.25, 0.82), P = 0.009) at short-term follow-up than endovascular coiling. However, neurosurgical clipping showed a higher incidence of ischemic infarction (OR:2.28, 95% CI (1.44, 3.63), P < 0.001) and a longer length of stay (LOS) (WMD:6.12, 95% CI (4.19, 8.04), P < 0.001) after surgery than endovascular coiling. Furthermore, the pooled results showed no statistically significant differences between the two groups regarding poor outcome, long-term mortality, rebleeding, vasospasm, and hydrocephalus. Evidence from this systematic review illustrates that neurosurgical clipping may be superior to endovascular coiling for ruptured anterior circulation aneurysms. Large-scale RCTs should be conducted to verify these outcomes and provide results according to patient status.

Endovascular coiling versus microsurgical clipping for ruptured intracranial aneurysms: a meta-analysis and systematic review

Background

The purpose of this analysis is to evaluate the current evidence with regard to the effectiveness and safety between coiling and clipping in patients with ruptured intracranial aneurysms (RIAs).

Methods

We performed a meta-analysis that compared clipping with coiling between July 2000 and September 2021. PubMed, EMBASE, and the Cochrane Library were searched for related articles systematically. And the treatment efficacy and postoperative complications were analyzed.

Results

We identified three randomized controlled trials and thirty-seven observational studies involving 60,875 patients with ruptured cerebral aneurysms. The summary results showed that coiling was related a better quality of life (mRS0-2; OR=1.327; CI=1.093–1.612; p<0.05), a higher risk of mortality (OR=1.116; CI=1.054–1.180; p<0.05), higher rate of rebleeding (RR=1.410; CI=1.092–1.822; p<0.05), lower incidence of vasospasm (OR=0.787; CI=0.649–0.954; p<0.05), higher risk of hydrocephalous (RR=1.143; CI=1.043–1.252; p<0.05), lower risk of cerebral infarction (RR=0.669; CI=0.596–0.751; p<0.05), lower risk of neuro deficits (RR=0.720; CI=0.582-0.892; p<0.05), and a lower rate of complete occlusion (OR=0.495; CI=0.280-0.876; p<0.05).

Conclusion

Coiling was significantly associated with a better life quality (mRS0-2), a lower incidence of postoperative complications, and a higher rate of mortality, rebleeding, hydrocephalous, and a lower rate of complete occlusion than clipping.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41016-022-00283-3.

Surgical Clipping of Ruptured Intracranial Aneurysm: Experience of a Tertiary Centre in Western India

Background Surgical clipping has been a gold standard procedure for management of intracranial aneurysms. Outcome studies of surgical clipping at institutional level are important to identify modifiable factors and further improve the results. These are even more important in areas where resources are limited, and patient presents late due to ignorance and lack of education. This study is a review of our institutional experience in microsurgical clipping of ruptured intracranial aneurysms.

Methods A retrospective study of patients who underwent surgical clipping for ruptured intracranial aneurysms from January 2014 to February 2020. The medical records of patients were reviewed for demographic data, clinical presentation, radiological investigations, surgery performed and neurological outcome. Outcome at discharge and outcome at follow-up were measured by modified Rankin scale (mRS).

Results In this study of 289 patients, 194 patients (67.13%) had good outcome at discharge (mRS0–2), while 95 patients (32.87%) had poor outcome at discharge (mRS 3–6) and 50 patients (17.30%) expired during hospital stay. Out of 289 patients, 208 patients (71.97%) were admitted after more than 3 days of ictus. Significant factors affecting outcome were neurological status determined by Glasgow coma scale (GCS) score, World Federation of Neurosurgical Societies (WFNS) grade or Hunt and Hess Grade, time interval from onset of subarachnoid hemorrhage to admission, and time interval from admission to surgery.

Conclusion The present study identifies factors for improving outcome in patients of ruptured aneurysm at institutional and community level. Time from ictus to admission and admission to surgery are important modifiable factors in our study.

Endovascular Intervention Versus Surgery in Ruptured Intracranial Aneurysms in Equipoise

Background and Purpose—

The benefits of endovascular intervention over surgery in the treatment of ruptured aneurysms of anterior circulation remains uncertain. Recently, published studies did not find superiority of endovascular intervention, challenging earlier evidence from a clinical trial. The earlier evidence also had a higher than average proportion of patients in good clinical status, leading to uncertainty about external validity of earlier trials.

Methods—

We performed a systematic review of studies after 2005 under a protocol published in the International Prospective Register of Systematic Reviews. Primary outcomes were posttreatment rebleeding and adverse events (procedural complications). Secondary outcomes were dependency at 3 to 6 and 12 months, delayed cerebral ischemia, and seizures.

Results—

Rebleeding was more frequent after endovascular intervention (Peto OR, 2.18 [95% CI, 1.29–3.70]; 3104 participants; 15 studies; I 2 =0%, Grading of Recommendations, Assessment, Development and Evaluation: very low certainty of evidence). Fewer adverse events were reported with the endovascular intervention (RR, 0.71 [95% CI, 0.53–0.95]; 1661 participants; 11 studies; I 2 =14%, Grading of Recommendations, Assessment, Development and Evaluation: low certainty of evidence). Three to six months dependency (RR, 0.82 [95% CI, 0.73–0.93]; 4081 participants; 18 studies; I 2 =15%, Grading of Recommendations, Assessment, Development and Evaluation: low certainty of evidence) and 12-month dependency (RR, 0.76 [95% CI, 0.66–0.86]; 1981 participants; 10 studies; I 2 =0%, Grading of Recommendations, Assessment, Development and Evaluation: low certainty of evidence) were lower after endovascular intervention.

Conclusions—

This study found consistent results between recent studies and the earlier evidence, in that endovascular intervention results in lower chance of dependency compared with surgery for repair of ruptured anterior circulation aneurysms. A lower proportion of patients in good clinical status in this review supports the application of the earlier evidence.

Registration—

URL: https://www.crd.york.ac.uk/PROSPERO . Unique identifier: CRD42018090396.

Endovascular Coiling Versus Neurosurgical Clipping for Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis

Background Aneurysmal subarachnoid hemorrhage is a frequently devastating condition with a reported incidence of between 10 and 15 people per 100,000 in the United States. Currently, according to the best of our knowledge, there are not enough meta-analyses available in the medical literature of the last five years which compare the risks and benefits of endovascular coiling with neurosurgical clipping. Methods Twenty-two studies were selected out of the short-listed studies. The studies were selected on the basis of relevance to the topic, sample size, sampling technique, and randomization. Data were analyzed on Revman software. Results Mortality was found to be significantly higher in the endovascular coiling group (odds ratio (OR): 1.17; confidence interval (CI): 95%, 1.04, 1.32). Re-bleeding was significantly higher in endovascular coiling (OR: 2.87; CI: 95%, 1.67, 4.93). Post-procedure complications were significantly higher in neurosurgical clipping compared to endovascular coiling (OR: 0.36; CI: 95%, 0.24, 0.56). Neurosurgical clipping was a 3.82 times better surgical technique in terms of re-bleeding (Z = 3.82, p = 0.0001). Neurosurgical clipping is a better technique requiring fewer re-treatments compared to endovascular coiling (OR: 4.64; CI: 95%, 2.31, 9.29). Endovascular coiling was found to be a better technique as it requires less rehabilitation compared to neurosurgical clipping (OR: 0.75; CI: 95%, 0.64,0.87). Conclusion Neurosurgical clipping provides better results in terms of mortality, re-bleeding, and re-treatments. Endovascular coiling is a better surgical technique in terms of post-operative complications, favorable outcomes, and rehabilitation.

Outcome of Ruptured Posterior Communicating Artery Aneurysm Treatment Comparing Between Clipping and Coiling Techniques

BACKGROUND

Very few data stratify the functional outcome of ruptured posterior communicating artery (PCoA) aneurysm treatment based on each treatment strategy. Therefore, the authors aimed to evaluate the outcome of PCoA aneurysm treatment to compare the clipping and coiling techniques and find the factors that determined the treatment outcomes.

METHODS

Patients with ruptured PCoA aneurysm at Songklanagarind Hospital between November 2002 and March 2018 were retrospectively reviewed and classified into the clipping group or the coiling group. The primary outcome was the modified Rankin Scale (mRS) at 6 months after treatment, and the patients were stratified into "good outcome" (mRS 0-2) and "poor outcome" (mRS 3-6). Using logistic regression analysis, various factors were analyzed for association with the treatment outcome.

RESULTS

This study included 189 patients: 104 and 85 patients in the clipping and coiling groups, respectively. Patients in the coiling group were significantly older, with more underlying diseases. However, the treatment outcomes at 6 months were not significantly different between the 2 groups. The percentages of poor outcomes in the clipping and coiling groups were 28% and 31%, respectively (P = 0.734). Older age, seizure, higher Hunt and Hess grade, deterioration before aneurysm obliteration, an aneurysm on the left side, and a medially projected PCoA aneurysm were statistically significantly correlated with poor outcomes.

CONCLUSIONS

Neurosurgical clipping and endovascular coiling are effective treatments for aneurysm obliteration in ruptured PCoA aneurysm. An aneurysm on the left side and a medially projected PCoA aneurysm were the factors correlated with poor outcome.

Microneurosurgical Clip Ligation of Acutely Ruptured Cerebral Aneurysm Immediately Preceded by Intentional Subtotal Endovascular Coil Embolization Under a Single Anesthesia: Observations Using a Deliberate Combined Sequential Treatment Strategy in 13 Cases

BACKGROUND

Endovascular coil embolization and craniotomy with clip ligation are the 2 most commonly used treatments for ruptured cerebral aneurysm. Although coiling maintains the advantages of brevity and complete avoidance of brain retraction and manipulation, clipping offers the benefits of decompression of the injured brain and lower rates of aneurysm recurrence. A combined, immediately sequential treatment strategy for acutely ruptured cerebral aneurysm that simultaneously maximizes the advantages of both techniques, while minimizing their respective disadvantages, may be a useful paradigm.

OBJECTIVE

To demonstrate the complementarity of clipping and coiling in acutely ruptured cerebral aneurysm.

METHODS

Patients with ruptured anterior circulation cerebral aneurysm standing to benefit from brain decompression were treated by a combination of coiling and microneurosurgery in rapid succession, under the same general anesthetic. Surgery consisted of clipping of the aneurysm via either craniotomy or craniectomy with expansion duraplasty in all cases, and ventriculostomy in selected cases.

RESULTS

Coil embolization of the ruptured aneurysm was carried out rapidly and improved the efficiency of subsequent clipping by allowing early unequivocal identification of the aneurysm dome and decreased brain retraction, reducing risk of intraoperative rupture and obviating temporary occlusion. All aneurysms were shown eliminated by postoperative cerebral angiography.

CONCLUSIONS

A deliberate combined treatment strategy that uses clipping immediately preceded by subtotal coiling under a single anesthetic may be ideal for selected ruptured cerebral aneurysms, takes advantage of the unique strengths of both techniques, makes both techniques easier, and maximizes opportunity for brain protection against delayed complications in the prolonged aftermath of aneurysmal subarachnoid hemorrhage.

Clipping Versus Coiling in Anterior Circulation Ruptured Intracranial Aneurysms: A Meta-Analysis

OBJECTIVE

To evaluate open surgical versus endovascular repair of anterior circulation ruptured intracranial aneurysms based on operative mortality, permanent neurologic deficit, late mortality, and need for reintervention.

METHODS

This meta-analysis included articles published since December 6, 2016, that compared outcomes of the 2 methods. Extracted data were organized in a standard table format, including first author, country, covered study period, publication year, number of patients and patients at follow-up, operative mortality rate (with 30 days from treatment), permanent neurologic deficit (appearing after surgery), late mortality (after 1 month), and reintervention (surgery or coiling) for both groups of patients. Follow-up was at least 1 year.

RESULTS

There were 8 articles that matched our study criteria. The study population was 628 patients; 374 were treated with surgical clipping, and 254 were treated with endovascular coiling. Pooled results showed no statistically significant difference between the 2 groups in terms of operative mortality, permanent neurologic deficit, late mortality, and need for reintervention.

CONCLUSIONS

Selection of the appropriate procedure must be made on the basis of the special characteristics of each case.

Clinical outcome after surgical clipping or endovascular coiling for cerebral aneurysms: a pragmatic meta-analysis of randomized and non-randomized trials with short- and long-term follow-up

BACKGROUND

Two randomized trials have evaluated clipping and coiling in patients with ruptured aneurysms. Aggregated evidence for management of ruptured and unruptured aneurysms is missing.

OBJECTIVE

To conduct a meta-analysis evaluating clinical outcome after aneurysm treatment.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov were searched for studies evaluating aneurysm treatment. The primary outcome measure was an independent clinical outcome (modified Rankin scale 0-2, Glasgow Outcome Scale 4-5, or equivalent). Secondary outcomes were poor outcome and mortality. ORs were calculated on an intention-to-treat basis with 95% CIs. Outcome heterogeneity was evaluated with Cochrane's Q test (significance level cut-off value at <0.10) and I² (significance cut-off value >50%) with the Mantel-Haenszel method for dichotomous outcomes. A p value <0.05 was regarded as statistically significant.

RESULTS

Searches yielded 18 802 articles. All titles were assessed, 403 abstracts were evaluated, and 183 full-text articles were read. One-hundred and fifty articles were qualitatively assessed and 85 articles were included in the meta-analysis. Patients treated with coiling (randomized controlled trials (RCTs)) had higher independent outcome at short-term follow-up (OR=0.67, 95% CI 0.57 to 0.79). Independent outcome was favored for coiling at intermediate and long-term follow-up (RCTs and observational studies combined-OR=0.80, 0.68 to 0.94 and OR=0.81, 0.71 to 0.93, respectively). Independent outcome and lower mortality was favored after coiling in unruptured aneurysms (database registry studies) at short-term follow-up (OR=0.34, 0.29 to 0.41 and OR=1.74, 1.52 to 1.98, respectively).

CONCLUSIONS

This meta-analysis evaluating clinical outcome after coiling or clipping for intracranial aneurysms, indicates a higher independent outcome and lower mortality after coiling.