Efficacy and Safety of Treatment of Ruptured Intracranial Aneurysms

Noncurative microsurgery for cerebral aneurysms: a systematic review and meta-analysis of wrapping, residual, and recurrence rates

OBJECTIVE

Microsurgery for cerebral aneurysms is called definitive, yet some patients undergo a craniotomy that results in noncurative treatment. Furthermore, the overall rate of noncurative microsurgery for cerebral aneurysms is unclear. The objective of this study was to complete a systematic review and meta-analysis to quantify three scenarios of noncurative treatment: aneurysm wrapping, postclipping remnants, and late regrowth of completely obliterated aneurysms.

METHODS

A PRISMA-guided systematic literature review of the MEDLINE and Cochrane Library databases and meta-analysis was completed. Studies were included that detailed rates of aneurysm wrapping, residua confirmed with imaging, and regrowth after confirmed total occlusion. Pooled rates were subsequently calculated using a random-effects model. An assessment of statistical heterogeneity and publication bias among the included studies was also completed for each analysis, with resultant I2 values and p values determined with Egger's test.

RESULTS

Sixty-four studies met the inclusion criteria for final analysis. In 41 studies, 573/15,715 aneurysms were wrapped, for a rate of 3.5% (95% CI 2.7%-4.2%, I2 = 88%). In 43 studies, 906/13,902 aneurysms had residual neck or dome filling, for a rate of 6.4% (95% CI 5.2%-7.6%, I2 = 93%). In 15 studies, 71/2568 originally fully occluded aneurysms showed regrowth, for a rate of 2.1% (95% CI 1.2%-3.1%, I2 = 58%). Together, there was a total rate of noncurative surgery of 12.0% (95% CI 11.5%-12.5%). Egger's test suggested no significant publication bias among the studies. Meta-regression analysis revealed that the reported rate of aneurysm wrapping has significantly declined over time, whereas the rates of aneurysm residua and recurrence have not significantly changed.

CONCLUSIONS

Open microsurgery for cerebral aneurysm results in noncurative treatment approximately 12% of the time. This metric may be used to counsel patients and as a benchmark for other treatment modalities. This investigation is limited by the high degree of heterogeneity among the included studies.

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

Neurosurgical clipping and endovascular coiling are both standard therapies to prevent rebleeding after aneurysmal subarachnoid hemorrhage (aSAH). However, controversy still exists about which is the optimal treatment. This meta-analysis aims to assess the effectiveness and safety of two treatments with high-quality evidence. Web of Science, Cochrane Library, EMBASE, Pubmed, Sinomed, China National Knowledge Infrastructure, and Wanfang Data databases were systematically searched on August 5, 2021. Randomized controlled trials (RCTs) and prospective cohort studies that evaluated the effectiveness and safety of clipping versus coiling in aSAH patients at discharge or within 1-year follow-up period were eligible. No restriction was set on the publication date. Meta-analyses were conducted to calculate the pooled estimates and 95% confidence intervals (CI) of relative risk (RR). Eight RCTs and 20 prospective cohort studies were identified. Compared to coiling, clipping was associated with a lower rebleeding rate at discharge (RR: 0.52, 95% CI: 0.29––0.94) and a higher aneurysmal occlusion rate (RR: 1.33, 95% CI: 1.19–1.48) at 1-year follow-up. In contrast, coiling reduced the vasospasm rate at discharge (RR: 1.45, 95% CI: 1.23–1.71) and 1-year poor outcome rate (RR: 1.27, 95% CI: 1.16–1.39). Subgroup analyses presented that among patients with a poor neurological condition at admission, no statistically significant outcome difference existed between the two treatments. The overall prognosis was better among patients who received coiling, but this advantage was not significant among patients with a poor neurological condition at admission. Therefore, the selection of treatment modality for aSAH patients should be considered comprehensively.

Neurocritical care complications and interventions influence the outcome in aneurysmal subarachnoid hemorrhage

Background

This observational study was performed to show the impact of complications and interventions during neurocritical care on the outcome after aneurysmal subarachnoid hemorrhage (SAH).

Methods

We analyzed 203 cases treated for ruptured intracranial aneurysms, which were classified regarding clinical outcome after one year according to the modified Rankin Scale (mRS). We reviewed the data with reference to the occurrence of typical complications and interventions in neurocritical care units.

Results

Decompressive craniectomy (odds ratio 21.77 / 6.17 ; p < 0.0001 / p = 0.013), sepsis (odds ratio 14.67 / 6.08 ; p = 0.037 / 0.033) and hydrocephalus (odds ratio 3.71 / 6.46 ; p = 0.010 / 0.00095) were significant predictors for poor outcome and death after one year beside “World Federation of Neurosurgical Societies” (WFNS) grade (odds ratio 3.86 / 4.67 ; p < 0.0001 / p < 0.0001) and age (odds ratio 1.06 / 1.10 ; p = 0.0030 / p < 0.0001) in our multivariate analysis (binary logistic regression model).

Conclusions

In summary, decompressive craniectomy, sepsis and hydrocephalus significantly influence the outcome and occurrence of death after aneurysmal SAH.

Dynamics of outcome after aneurysmal subarachnoid hemorrhage

In this observational study, we analyzed and described the dynamics of the outcome after aneurysmal subarachnoid hemorrhage (SAH) in a collective of 203 cases. We detected a significant improvement of the mean aggregate modified Rankin Score (mRS) in every time interval from discharge to 6 months and up to 1 year. Every forth to fifth patient with potential of recovery (mRS 1-5) at discharge improved by 1 mRS point in the time interval from 6 month to 1 year (22.6%). Patients with mRS 3 at discharge had a remarkable late recovery rate (73.3%, p = 0.000085). Multivariate analysis revealed age ≤ 65 years (odds ratio 4.93; p = 0.0045) and "World Federation of Neurological Surgeons" (WFNS) grades I and II (odds ratio 4.77; p = 0.0077) as significant predictors of early improvement (discharge to 6 months). Absence of a shunting procedure (odds ratio 8.32; p = 0.0049) was a significant predictor of late improvement (6 months to 1 year), but not age ≤ 65 years (p = 0.54) and WFNS grades I and II (p = 0.92). Thus, late recovery (6 month to 1 year) is significant and independent from age and WFNS grade.

Impact of Complications and Comorbidities on the Intensive Care Length of Stay after Aneurysmal Subarachnoid Haemorrhage

In this observational study, we analysed a cohort of 164 subarachnoid haemorrhage survivors (until discharge from intensive care) with the aim to detect factors that influence the length of stay (LOS) in intensive care with multiple linear regression methods. Moreover, binary logistic regression methods were used to examine whether the time in intensive care is a predictor of outcome after 1 year. The clinical 1-year outcome was measured prospectively in a 12-month follow-up by telephone interview and categorised by the modified Rankin Scale (mRS). Patients who died during their stay in intensive care were excluded. Complications like pneumonia (β = 5.11; 95% CI = 1.75–8.46; p = 0.0031), sepsis (β = 9.54; 95% CI = 3.27–15.82; p = 0.0031), hydrocephalus (β = 4.63; 95% CI = 1.82–7.45; p = 0.0014), and delayed cerebral ischemia (DCI) (β = 3.38; 95% CI = 0.19–6.56; p = 0.038) were critical factors depending the LOS in intensive care as well as decompressive craniectomy (β = 5.02; 95% CI = 1.35–8.70; p = 0.0077). All analysed comorbidities such as hypertension, diabetes, hypothyroidism, cholesterinemia, and smoking history had no significant impact on the LOS in intensive care. LOS in intensive care (OR = 1.09; 95% CI = 1.03–1.15; p = 0.0023) as well as WFNS grade (OR = 3.72; 95% CI = 2.23–6.21; p < 0.0001) and age (OR = 1.06; 95% CI = 1.02–1.10; p = 0.0061) were significant factors that had an impact on the outcome after 1 year. Complications in intensive care but not comorbidities are associated with higher LOS in intensive care. LOS in intensive care is a modest but significant predictor of outcomes after subarachnoid haemorrhage.

Racial and Ethnic Disparities in Treatment Outcomes of Patients with Ruptured or Unruptured Intracranial Aneurysms

OBJECTIVE

The aim of this study is to examine how health outcomes varied by treatment selection and race/ethnicity among hospitalized US patients with ruptured or unruptured IAs.

METHODS

A retrospective cohort study was conducted using a sample of 62,224 hospital discharges from the 2002-2012 Nationwide Inpatient Sample. Logistic regression models evaluated treatment selection as predictor of in-hospital survival (IHS: "yes," "no") and length of stay (LOS ≤ 7 days, > 7 days), overall and across racial/ethnic groups, taking hospital- and patient-level confounders into account, while stratifying by IA rupture status.

RESULTS

Compared to surgical clipping, endovascular coiling was associated with better IHS, after controlling for confounders. Compared to surgical clipping, LOS ≤ 7 days was less likely in patients with combination of treatments and more likely among patients with endovascular coiling as well as balloon- or stent-assisted coiling. Observed relationships varied significantly by race and ethnicity for IHS, but not for LOS ≤ 7 days. Whereas combination of treatments were associated with worse IHS than surgical clipping among Blacks alone, endovascular coiling was associated with better IHS than surgical clipping among White and Other racial/ethnic subgroups. These relationships were for the most part consistent among patients with and without IA rupture.

CONCLUSIONS

Racial and ethnic subgroups of IA patients experienced differential IHS by treatment selection, irrespective of IA rupture status. Prospective cohort studies are needed to further elucidate these racial and ethnic disparities, while collecting data on IA size, location, and morphology as well as Hunt and Hess grade for ruptured IA.

Impact of Comorbidities and Smoking on the Outcome in Aneurysmal Subarachnoid Hemorrhage

The intention of this observational study is to show the significant impact of comorbidities and smoking on the outcome in aneurysmal subarachnoid hemorrhage (SAH). During this observational study 203 cases of treatment of ruptured intracranial aneurysms were analyzed. We examined and classified prospectively the 12 month outcome according to the modified Rankin Scale (mRS) considering retrospectively a history of smoking and investigated prospectively the occurrence of early and delayed cerebral ischemia between 2012 and 2017. Using logistic regression methods, we revealed smoking (odds ratio 0.21; p = 0.0031) and hypertension (odds ratio 0.18; p = 0.0019) to be predictors for a good clinical outcome (mRS 0-2). Age (odds ratio 1.05; p = 0.0092), WFNS Grade (odds ratio 6.28; p < 0.0001), early cerebral ischemia (ECI) (odds ratio 10.06; p < 0.00032) and delayed cerebral ischemia (DCI) (odds ratio 4.03; p = 0.017) were detected as predictors for a poor clinical outcome. Significant associations of occurrence of death with hypertension (odds ratio 0.12; p < 0.0001), smoking (odds ratio 0.31; p = 0.048), WFNS grade (odds ratio 3.23; p < 0.0001) and age (odds ratio 1.09; p < 0.0001), but not with ECI (p = 0.29) and DCI (p = 0.62) were found. Smoking and hypertension seem to be predictors for a good clinical outcome after aneurysmal SAH.

Treatment of ruptured intracranial aneurysms yesterday and now

Objective

This prospective study is designed to detect changes in the treatment of ruptured intracranial aneurysms over a period of 17 years.

Methods

We compared 361 treated cases of aneurysm occlusion after subarachnoid hemorrhage from 1997 to 2003 with 281 cases from 2006 to 2014. Specialists of neuroradiology and vascular neurosurgery decided over the modality assignment. We established a prospective data acquisition in both groups to detect significant differences within a follow-up time of one year. With this setting we evaluated the treatment methods over time and compared endovascular with microsurgical treatment.

Results

When compared to the earlier group, microsurgical treatment was less frequently chosen in the more recent collective because of neck-configuration. Endovascular treatment was chosen more frequently over time (31.9% versus 48.8%). Occurrence of initial symptomatic ischemic stroke was significantly lower in the clipping group compared to the endovascular group and remained stable over time. The number of reinterventions due to refilled treated aneurysms significantly decreased in the endovascular group at one-year follow-up, but the significantly better occlusion- and reintervention-rate of the microsurgical group persisted. The rebleeding rate in the endovascular group at one year follow-up decreased from 6.1% to 2.2% and showed no statistically significant difference to the microsurgical group, anymore (endovascular 2.2% versus microsurgical 0.0%, p = 0.11).

Conclusion

Microsurgical clipping still has some advantages, however endovascular treatment is improving rapidly.