Endovascular coiling versus neurosurgical clipping in the management of aneurysmal subarachnoid haemorrhage in the elderly: a multicenter cohort study

The comparability of endovascular coiling over neurosurgical clipping has not been firmly established in elderly patients with aneurysmal subarachnoid haemorrhage (aSAH). Data were obtained from all patients with aSAH aged ≥60 across three tertiary hospitals in Singapore from 2014 to 2019. Outcome measures included modified Rankin Scale (mRS) score at 3 and at 6 months, and in-hospital mortality. Of the 134 patients analyzed, 84 (62.7%) underwent coiling and 50 (37.3%) underwent clipping. The endovascular group showed a higher incidence of good mRS score 0-2 at 3 months (OR = 2.45 [95%CI:1.16-5.20];p = 0.018), and a lower incidence of in-hospital mortality (OR = 0.31 [95%CI:0.10-0.91];p = 0.026). There were no significant difference between the two treatment groups in terms of good mRS score at 6 months (OR = 1.98 [95%CI:0.97-4.04];p = 0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (OR = 0.32 [95%CI:0.12-0.90];p = 0.025). Age, admission WFNS score I-III, and coiling were independent predictors of good functional outcomes at 3 months. Only age and admission WFNS score I-III remained significant predictors of good functional outcomes at 6 months. Endovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores.

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.

Supraorbital eyebrow keyhole approach for microsurgical management of ruptured anterior communicating artery aneurysm

The mortality and disability rate of patients with ruptured anterior communicating artery (AComA) aneurysm after bleeding is high. Even with the most advanced treatment methods, the incidence of complications remains high. The purpose of the present study was to determine the efficacy of microsurgery via supraorbital eyebrow keyhole approach (SOEK) in clipping ruptured AComA aneurysms. Between September 2010 and October 2018, 543 patients with intracranial aneurysms were admitted to the Department of Neurosurgery of the Third Affiliated Hospital of Sun Yat-Sen University (Guangzhou, China). Among them, 85 patients with ruptured AComA aneurysm and subarachnoid hemorrhage (SAH) underwent microsurgical clipping via the SOEK approach. In those patients, the clipping rate, complications and clinical efficacy of treatment were evaluated. The average age of the patients was 52.69±9.94 years (range, 28-78 years). The proportions of small, medium and large aneurysms were 83.5, 15.3 and 1.2%, respectively. Procedural complications occurred in 9 cases (10.5%). The occlusion rate of the aneurysms was 98.8%. The average follow-up period was 37.9 (±24.5) months. A total of 81.2% of the patients with SAH had a good clinical prognosisat 1 year (modified Rankin scale score, ≤2). In conclusion, for a skilled and experienced surgeon, SOEK was indicated to be a safe procedure for the treatment of ruptured AComA aneurysms; it provided sufficient intra-operative exposure and a high clipping rate.

Shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

INTRODUCTION

Shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH) is the occurrence of symptomatic ventriculomegaly requiring permanent shunt diversion. Although several studies investigated the predictors of SDHC, the role of many of these factors, as well as the prevalence of SDHC and patients' clinical outcome, remain a matter of controversy.

EVIDENCE ACQUISITION

According to PRISMA guidelines we performed a systematic search looking into four databases with the purpose of clarifying the prevalence of SDHC after aSAH, the predictors of SDHC, the mortality rate and clinical outcome of patients with and without SDHC.

EVIDENCE SYNTHESIS

Our analysis included 23 studies involving 22,264 patients. The overall prevalence of SDHC was 22.3% (95% CI: 17.9-26.6%). The predictors of SDHC included radiological hydrocephalus at presentation (OR 6.3, 95% CI: 2.27-17.51%), external ventricular drainage insertion (OR 5.7, 95% CI: 3.77-8.61%), high Hunt and Hess scale score (HHS 3-5: OR 3.3, 95% CI: 2.64-4.15%; HHS 4-5: OR 3.2, 95% CI: 2.4-4.2%), high Fisher grade (OR 3.1, 95% CI: 2.58-3.72%), intraventricular blood (OR 3.1, 95% CI: 2.60-3.71%), vasospasm (OR 1.9, 95% CI: 1.30-2.81%), intraparenchymal hemorrhage (OR 1.8, 95% CI: 1.2-2.78%), female gender (OR 1.3, 95% CI: 1.14-1.65%) and posterior circulation aneurysms (OR 1.4, 95% CI: 1.11-1.71%). The modality of aneurysm repair did not affect the rate of permanent shunt diversion. Patients with SDHC were more likely to be associated with a poor clinical outcome (mRS 3-6) (OR 4.3), even if mortality rate was similar between shunted and non-shunted patients (9%, 95% CI: 2-16% vs. 10.8%, 95% CI: 3.2-18.5%) (P=0.09).

CONCLUSIONS

The prevalence of SDHC is 22.3%. Our analysis identified several predictors of SDHC that can assist clinicians in monitoring patients with an aSAH. Shunt dependency is not related to the treatment modality of the ruptured aneurysm, whereas the occurrence of SDHC is a predictor of poor clinical outcome.

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.

Engaging in a Keyhole Concept for the Management of Ruptured and Unruptured Aneurysms

OBJECTIVE

Many new endovascular devices have been used under the guidance of the International Subarachnoid Aneurysm Trial. Clipping still offers higher occlusion rates, and its technique continues to evolve, resulting in smaller exposures and reduced manipulation to brain tissue. We sought to evaluate the routine use of the minisphenoidal approach to manage intracranial aneurysms in a high-volume institution.

METHODS

We retrospectively reviewed our database of patients with aneurysm from October 2013 to May 2016. Data were originally collected prospectively. The minisphenoidal approach has been progressively replacing the pterional approach for managing aneurysms in our department. Occlusion rates for ruptured and unruptured aneurysms were analyzed using late follow-up angiograms. Functional outcome assessment and the impact on quality of life were also measured.

RESULTS

We performed 124 minisphenoidal craniotomies in 117 patients to clip 147 aneurysms. Patient mean age was 53.9 years. Seventy patients (59.8%) presented with subarachnoid hemorrhage. Middle cerebral artery aneurysms represented 48% of the total number of aneurysms; posterior communicating artery aneurysms represented 24%. The minisphenoidal craniotomy was helpful in managing superior cerebellar artery aneurysms and 1 ruptured orbitofrontal artery aneurysm. We achieved an occlusion rate of 97.8%, with a mean follow-up of 13.2 months. Favorable outcomes were achieved for 79% of patients with subarachnoid hemorrhage and for 98% of unruptured patients.

CONCLUSIONS

Evolution of endovascular techniques has paved the way for minimizing surgical exposures. Routine use of the minisphenoidal approach for managing ruptured, unruptured, and previously coiled aneurysms is safe and provides adequate exposure with robust occlusion rates.

Early outcomes and perioperative complications of endovascular embolization in patients with aneurysmal SAH

BACKGROUND

We still lack reliable data on the outcomes of endovascular coiling for ruptured cerebral aneurysms. As this is still an evolving technique, the outcomes of the procedures performed in the past and more recently cannot be directly compared. We present the early outcomes of endovascular coiling in a relatively large group of patients with ruptured intracranial aneurysms.

METHOD

The study included 190 consecutive patients (a total of 216 aneurysms) subjected to endovascular coiling in 2006-2013 (127 women aged 56±13 years and 63 men aged 50± 15 years). Up to 87.5% of the aneurysms were located within anterior circulation. Most patients presented with "mild to moderate" subarachnoid hemorrhages (85% of Hunt &Hess scores 1-3, and 72% of Fisher scores 1-3).

RESULTS

Embolization was feasible in 176 (92.6%) patients. In 14 cases, the embolization was not attainable due to unfavorable anatomy of the aneurysm, intraoperative vasospasm and/or aneurysm rupture, or prolapse of a coil. Early complications related to the procedure were recorded in 23 (13.1%) patients. The most common perioperative complication was aneurysm rupture. All fatal complications occurred in patients with aneurysms located at the anterior circle of Willis. At the time of discharge, 126 patients scored 4 or 5 on the Glasgow Outcome Scale.

CONCLUSIONS

Endovascular embolization is an effective and relatively safe method for treatment of ruptured cerebral aneurysms. Complications related to the procedure are significantly less frequent in the case of vertebral-basilar complex aneurysms.

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.