1
|
de Liyis BG, Surya SC, Tini K. Effectivity and safety of endovascular coiling versus microsurgical clipping for aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. Clin Neurol Neurosurg 2024; 236:108058. [PMID: 38056041 DOI: 10.1016/j.clineuro.2023.108058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/24/2023] [Accepted: 11/22/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND There is an ongoing lack of consensus among clinicians regarding on the optimal aneurysmal subarachnoid hemorrhage (aSAH) management approach between endovascular coiling and microsurgical clipping. METHODS Comprehensive literature search for randomized controlled trials (RCTs) was conducted in Medline and Cochrane databases until January 1st, 2023 without language constraints. Effectivity outcomes included one-year mortality, one-year poor outcomes, and one-year complete aneurysmal occlusion, while safety outcomes comprised the incidence of vasospasms, rebleeding, post-operative complications, and cerebral ischemia. RESULTS Eight RCTs, involving 3585 aSAH patients, underwent comprehensive quantitative analysis. Among them, 1792 underwent endovascular coiling and 1773 patients had microsurgical clipping. Regarding effectivity, the rates of one-year mortality (OR: 0.79, 95% CI: 0.61-1.03, p = 0.08) exhibited no significant difference. However, endovascular coiling demonstrated an inferior one-year complete aneurysmal occlusion rate (OR: 0.33, 95% CI: 0.21-0.53, p < 0.00001), although with significantly lower rates of poor outcomes (OR: 0.68, 95% CI: 0.57-0.81, p < 0.00001) compared to the microsurgical clipping group. As for safety, endovascular coiling group exhibited lower rates of vasospasm (OR: 0.58, 95% CI: 0.36-0.92, p = 0.02), post-operative complications (OR: 0.40, 95% CI: 0.23-0.71, p = 0.02), and cerebral ischemia (OR: 0.36, 95% CI: 0.20-0.63, p = 0.0004). No significant effect on the incidence of rebleeding was observed (OR: 1.09, 95% CI: 0.73-1.63, p = 0.68). CONCLUSIONS Endovascular coiling proves superior and safer for aSAH patients, but consideration of resources, patient condition, and surgeon preferences is crucial for selecting the optimal approach.
Collapse
Affiliation(s)
| | | | - Kumara Tini
- Department of Neurology, Universitas Udayana, Denpasar, Bali, Indonesia
| |
Collapse
|
2
|
Peng C, Diao YH, Cai SF, Yang XY. Endovascular coiling versus microsurgical clipping for ruptured intracranial aneurysms: a meta-analysis and systematic review. Chin Neurosurg J 2022; 8:17. [PMID: 35879784 PMCID: PMC9310462 DOI: 10.1186/s41016-022-00283-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/17/2022] [Indexed: 11/26/2022] Open
Abstract
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.
Collapse
|
3
|
Long-term outcomes of ruptured saccular intracranial aneurysm clipping versus coiling: systematic review and meta-analysis of randomized controlled trials. Neurol Sci 2022; 43:4909-4915. [DOI: 10.1007/s10072-022-06039-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
|
4
|
Microsurgery as first-line treatment in acute hemorrhagic cranial dural arteriovenous fistulas (dAVFs) and ruptured intracranial aneurysms-anachronism or duty? Acta Neurochir (Wien) 2022; 164:1303-1305. [PMID: 35384499 DOI: 10.1007/s00701-022-05197-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 11/01/2022]
|
5
|
Zhang Z, Albadawi H, Fowl RJ, Altun I, Salomao MA, Jahanyar J, Chong BW, Mayer JL, Oklu R. Treatment of Ruptured and Nonruptured Aneurysms Using a Semisolid Iodinated Embolic Agent. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2022; 34:e2108266. [PMID: 34936720 PMCID: PMC8917094 DOI: 10.1002/adma.202108266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/18/2021] [Indexed: 06/14/2023]
Abstract
Saccular aneurysms (SAs) are focal outpouchings from the lateral wall of an artery. Depending on their morphology and location, minimally invasive treatment options include coil embolization, flow diverter stents, stent-assisted coiling, and liquid embolics. Many drawbacks are associated with these treatment options including recanalization, delayed healing, rebleeding, malpositioning of the embolic or stent, stent stenosis, and even rupture of the SA. To overcome these drawbacks, a nanoclay-based shear-thinning hydrogel (STH) is developed for the endovascular treatment of SAs. Extensive in vitro testing is performed to optimize STH performance, visualization, injectability, and endothelialization in cell culture. Femoral artery saccular aneurysm models in rats and in pigs are created to test stability, efficacy, immune response, endothelialization, and biocompatibility of STH in both ruptured and unruptured SA. Fluoroscopy and computed tomography imaging consistently confirmed SA occlusion without recanalization, migration, or nontarget embolization; STH is also shown to outperform coil embolization of porcine aneurysms. In pigs with catastrophic bleeding due to SA rupture, STH is able to achieve instant hemostasis rescuing the pigs in long-term survival experiments. STH is a promising semisolid iodinated embolic agent that can change the standard of medical practice and potentially save lives.
Collapse
Affiliation(s)
- Zefu Zhang
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Richard J. Fowl
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
- Chair Emeritus, Division of Vascular and Endovascular Surgery, Emeritus Professor of Surgery, Mayo Clinic, 5777 East Mayo Blvd., Phoenix, Arizona 85054, USA
| | - Izzet Altun
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Marcela A. Salomao
- Division of Anatomic Pathology & Laboratory Medicine, Department of Pathology, Mayo Clinic, 5777 East Mayo Blvd., Phoenix, Arizona 85054, USA
| | - Jama Jahanyar
- Division of Cardiothoracic Surgery, Mayo Clinic, 5777 East Mayo Blvd., Phoenix, Arizona 85054, USA
| | - Brian W. Chong
- Department of Neurological Surgery and Radiology, Mayo Clinic, 5777 East Mayo Blvd., Phoenix, Arizona 85054, USA
| | - Joseph L. Mayer
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| |
Collapse
|
6
|
Chen J, Feng X, Peng F, Tong X, Niu H, Liu A. Cost-Effective Analysis of Different Diagnostic Strategies in Screening for Aneurysms After Spontaneous Subarachnoid Hemorrhage. Acad Radiol 2022; 29 Suppl 3:S36-S43. [PMID: 33288399 DOI: 10.1016/j.acra.2020.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE With an increasing number of patients being treated by coiling for aneurysms, using computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) as an initial screening test becomes less important because digital subtraction angiography (DSA) is the first step of endovascular treatment procedure. The objective of this study is to investigate whether CTA or MRA remained to be the optimal screening strategy in patients with spontaneous subarachnoid hemorrhage (SAH). METHODS CTA, MRA, and DSA strategy were evaluated in a decision tree model created with TreeAge Pro Suite 2011. Input parameters were derived from published literature and our institutional database. Base case and sensitivity analyses were conducted to assess the cost-effectiveness of each strategy. A Monte Carlo simulation was performed with all parameters ranged among their distributions to evaluate the validation of results. RESULTS The base case scenario showed that MRA was the most cost-effective strategy. Using a willingness-to-pay threshold of ¥70,892/quality adjusted life year, MRA remained to be most cost-effective when its sensitivity is >0.907. DSA was not cost-effective compared to CTA or MRA unless over 91.56% of patients were treated by coiling. The Monte Carlo simulation reported DSA not to be a cost-effective strategy at willingness-to-pay of ¥70,892 in 99.99% of the iterations. CONCLUSION DSA is not cost-effective compared to CTA or MRA and should not be used as the initial diagnostic tool for spontaneous SAH.
Collapse
Affiliation(s)
- Jigang Chen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, China
| | - Xin Feng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, China
| | - Fei Peng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, China
| | - Hao Niu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, China.
| |
Collapse
|
7
|
Clipping versus coiling for aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of prospective studies. Neurosurg Rev 2021; 45:1291-1302. [PMID: 34870768 PMCID: PMC8976818 DOI: 10.1007/s10143-021-01704-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/07/2021] [Accepted: 11/24/2021] [Indexed: 11/03/2022]
Abstract
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.
Collapse
|
8
|
Duangthongphon P, Kitkhuandee A, Munkong W, Limwattananon P, Waleekhachonloet O, Rattanachotphanit T, Limwattananon S. Cost-effectiveness analysis of endovascular coiling and neurosurgical clipping for aneurysmal subarachnoid hemorrhage in Thailand. J Neurointerv Surg 2021; 14:942-947. [PMID: 34544826 DOI: 10.1136/neurintsurg-2021-017970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/27/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND For patients with aneurysmal subarachnoid hemorrhage (aSAH), the Universal Coverage Scheme in Thailand covers the full costs of surgical and endovascular procedures except for those of embolization coils and assisting devices. Costs and effectiveness were compared between endovascular coiling and neurosurgical clipping to inform reimbursement policy decisions. METHODS Costs and quality-adjusted life years (QALYs) were compared between coiling and clipping using the decision tree and Markov models. Mortality and functional outcomes of clipping were derived from national and hospital databases, and relative efficacies of coiling were obtained from meta-analyses of randomized controlled trials. Risks of rebleeding were abstracted from the International Subarachnoid Aneurysm Trial. Costs of the primary treatments, retreatments and follow-up care as well as utilities were obtained from hospital-based data. Non-health and indirect costs were abstracted from standard cost lists. RESULTS Coiling and clipping contributed 10.59 and 9.28 QALYs to patients aged in their 50s. Under the societal and healthcare perspectives, the incremental costs incurred by coiling compared with clipping were US$1923 and $4343, respectively, which were equal to the incremental cost-effectiveness ratio of US$1470 and $3321 per QALY gained, respectively. Coiling became a cost-saving option when the costs of coil devices were reduced by 65.7%. At the country's cost-effectiveness threshold of US$5156, the probability of coiling being cost-effective was 71.3% and 65.6%, under the societal and healthcare perspectives, respectively. CONCLUSION Endovascular treatment for aSAH is cost-effective and this evidence supports coverage by national insurance.
Collapse
Affiliation(s)
| | - Amnat Kitkhuandee
- Department of Surgery, Khon Kaen University Faculty of Medicine, Khon Kaen, Thailand
| | - Waranon Munkong
- Department of Radiology, Khon Kaen University Faculty of Medicine, Khon Kaen, Thailand
| | | | | | | | - Supon Limwattananon
- Division of Social and Administrative Pharmacy, Khon Kaen University Faculty of Pharmaceutical Sciences, Khon Kaen, Thailand
| |
Collapse
|
9
|
Revilla-Pacheco F, Calderón-Juárez M, Lerma A, Herrada-Pineda T, Lerma C. Efficacy of an intervention program to prevent patient safety indicators in aneurysmal subarachnoid haemorrhage. Br J Neurosurg 2021:1-6. [PMID: 34096815 DOI: 10.1080/02688697.2021.1931810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/24/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Patient safety indicators (PSI) are a set of potentially preventable events related to patient safety and opportunities for improvement. Eight pertinent PSI have been identified in patients with aneurysmal subarachnoid haemorrhage (ASAH), such as decubitus ulcer, and central line-related bacteraemia. Our aim was to evaluate the efficacy of a health care quality protocol to prevent the appearance of PSI in ASAH patients. METHODS Adult patients treated for ASAH were included in a retrospective control group of 35 patients and a prospective experimental group of 35 patients when the prevention program was implemented. We evaluated the occurrence of PSI, and its relation to age, sex, Hunt and Hess scale grade, type of aneurysm treatment, length of hospital stay, and Glasgow Outcome Scale scores. RESULTS Both groups had similar characteristics except for a longer hospital stay in the control group. The overall PSI prevalence decreased significantly in the experimental group compared to the control group. The experimental group had a decreased risk for having at least one PSI: OR = 0.21 (0.08-0.57, CI 95%). The absolute risk reduction is 37.1% (58.9%-15.4%), the preventable fraction for the population is 28.3% (10.6%-40.0%), and the number needed to treat is 2.69. CONCLUSIONS The health care quality protocol is effective to prevent ISP in ASAH patients. Implementing this prevention program has no effect on the neurological state of the patient at the hospital discharge. Still, it is successful in decreasing the PSI prevalence and the days of hospital stay.
Collapse
Affiliation(s)
| | - Martín Calderón-Juárez
- Department of Education, ABC Medical Center, Mexico City, Mexico
- Plan de Estudios Combinados en Medicina, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Abel Lerma
- Institute of Health Sciences, Universidad Autónoma del Estado de Hidalgo, San Juan Tilcuautla, Mexico
| | | | - Claudia Lerma
- Department of Electromechanical Instrumentation, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| |
Collapse
|
10
|
Management of Ruptured Intracranial Aneurysms in the Post-International Subarachnoid Aneurysm Trial Era: A Single-Centre Prospective Series. Can J Neurol Sci 2021; 49:62-69. [PMID: 33726874 DOI: 10.1017/cjn.2021.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is associated with significant morbidity and mortality. The International Subarachnoid Aneurysm Trial (ISAT) reported reduced morbidity in patients treated with endovascular coiling versus surgical clipping. However, recent studies suggest that there is no significant difference in clinical outcomes. This study examines the outcomes of either technique for treating aSAH during the 15 years post-ISAT at a Canadian quaternary centre. METHODS We reviewed prospectively collected data of patients admitted with aSAH from January 2002 to December 2017. Glasgow Outcome Scale (GOS) was compared at discharge, 6 months and 12 months' follow-up using univariate and multivariable ordinal logistic regression. Post-operative complications were assessed using binary logistic regression. RESULTS Two-hundred and eighty-seven patients were treated with coiling and 95 patients with clipping. The mean age of clipped patients was significantly younger, and hypertension was significantly commoner in coiled patients. A greater proportion of coiled aneurysms were located in the posterior circulation. No difference in the odds of having a favourable GOS was seen between patients who were clipped versus coiled at any of follow-up time points on univariate or multivariable analysis. In both treatment groups, patient recovery to independence (GOS 4-5) was seen from discharge to 6 months, but not from 6 to 12 months' follow-up, without difference between clipping and coiling. CONCLUSION These real-world findings suggest clipping remains an effective and important treatment option for patients with aSAH who do not meet ISAT inclusion criteria. The results can assist in clinical decision-making processes and understanding of the natural recovery progression of aSAH.
Collapse
|
11
|
Leacy RD, Kottenmeier E, Lee SH, Khanna R, Spiotta AM. Endovascular treatment with the Enterprise stent versus the Neuroform or Low-Profile Visualized Intraluminal Support stent for unruptured aneurysms. J Comp Eff Res 2021; 10:295-305. [PMID: 33595342 DOI: 10.2217/cer-2020-0202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To compare outcomes among patients undergoing endovascular treatment for unruptured intracranial aneurysm (UIA) with the Enterprise stent versus the Neuroform or Low-Profile Visualized Intraluminal Support (LVIS) stent. Patients & methods: Patients undergoing endovascular procedure for UIA were classified into Enterprise stent and Neuroform or LVIS stent group. Groups were propensity-score matched and generalized estimating equations were used for outcomes assessment. Results: There were no significant between-group differences in length of stay or mortality. The Enterprise group had significantly lower odds of UIA-related inpatient readmissions versus the Neuroform/LVIS group (odds ratio: 0.62; 95% CI: 0.42-0.91). Conclusion: Enterprise stent use was associated with significantly lower readmissions versus competitor stent, with no difference in other study outcomes.
Collapse
Affiliation(s)
- Reade De Leacy
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, USA
| | - Emilie Kottenmeier
- Johnson & Johnson Medical Devices, Franchise Health Economics & Market Access, Irvine, CA, USA
| | | | - Rahul Khanna
- Medical Device Epidemiology, Johnson & Johnson, New Brunswick, NJ, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
12
|
Anatomic feasibility of endoscopic endonasal intracranial aneurysm clipping: a systematic review of anatomical studies. Neurosurg Rev 2020; 44:2381-2389. [PMID: 33174136 DOI: 10.1007/s10143-020-01434-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/07/2020] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
Clinical studies have suggested the endoscopic endonasal approach (EEA) for aneurysm clipping as a feasible way to treat select intracranial aneurysms. Among neurosurgery, there is not a consensus on the utility of EEA aneurysm clipping. This review aims to define the anatomic feasibility of EEA for aneurysm clipping. Two databases (PubMed, Cochrane) were searched for anatomical studies assessing EEA for intracranial aneurysm clipping. Literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quantitative anatomical studies were included. Eleven studies met inclusion criteria. Vascular exposure and clip placement on vessels of interest were possible, although only one study assessed these parameters with physical aneurysm models. Anterior circulation vessels, although accessible in over 90% of specimens, had low successful clipping rates in a small and large aneurysm models. Small and large model posterior circulation aneurysms were more readily clipped. Proximal and distal controls were readily attainable in posterior circulation aneurysms, but not anterior. This current literature review highlights the relevance of anatomical studies in assessing the feasibility of the EEA for clipping intracranial aneurysms. As such, anterior circulation aneurysms are poor candidates for EEA given difficulties in clip placement and obtaining proximal control and distal control in small and large aneurysms. While our results suggest that clipping of posterior circulation aneurysms is feasible from a technical stand of view, further clinical experience is required to assess its feasibility in terms of safety and efficacy, balancing the indications with endovascular treatment options.
Collapse
|
13
|
Roquer J, Cuadrado-Godia E, Guimaraens L, Conesa G, Rodríguez-Campello A, Capellades J, García-Arnillas MP, Fernández-Candil JL, Avellaneda-Gómez C, Giralt-Steinhauer E, Jiménez-Conde J, Soriano-Tárraga C, Villalba-Martínez G, Vivanco-Hidalgo RM, Vivas E, Ois A. Short- and long-term outcome of patients with aneurysmal subarachnoid hemorrhage. Neurology 2020; 95:e1819-e1829. [PMID: 32796129 PMCID: PMC7682825 DOI: 10.1212/wnl.0000000000010618] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 06/08/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To describe short-term and 5-year rates of mortality and poor outcome in patients with spontaneous aneurysmal subarachnoid hemorrhage (aSAH) who received repair treatment. METHODS In this prospective observational study, mortality and poor outcome (modified Rankin Scale score 3-6) were analyzed in 311 patients with aSAH at 3 months, 1 year, and 5 years follow-up. Sensitivity analysis was performed according to treatment modality. In-hospital and 5-year complications were analyzed. RESULTS Of 476 consecutive patients with spontaneous subarachnoid hemorrhage, 347 patients (72.9%) had aSAH. Of these, 311 (89.6%) were treated (242 endovascular, 69 neurosurgical), with a mean follow-up of 43.4 months (range, 1 to 145). Three-month, 1-year, and 5-year mortality was 18.4%, 22.9%, and 29.0%, and poor outcome was observed in 42.3%, 36.0%, and 36.0%, respectively. Adjusted poor outcome was lower in endovascular than in neurosurgical treatment at 3 months (odds ratio [OR] 0.36 [95% confidence interval [CI] 0.18-0.74]), with an absolute difference of 15.8% (number needed to treat = 6.3), and at 1 year (OR = 0.40 [95% CI 0.20-0.81]), with an absolute difference of 15.9% (number needed to treat = 6.3). Complications did not differ between the 2 procedures. However, mechanical ventilation was less frequent with the endovascular technique (OR 0.67 [95% CI 0.54-0.84]). CONCLUSIONS Patients with aSAH treated according to current guidelines had a short-term mortality of 18.4% and 5-year mortality of 29%. The majority (64.0%) of patients remained alive without disabilities at 5-year follow-up. Patients prioritized to endovascular treatment had better outcomes than those referred to neurosurgery because endovascular coiling was not feasible.
Collapse
Affiliation(s)
- Jaume Roquer
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain.
| | - Elisa Cuadrado-Godia
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Leopoldo Guimaraens
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Gerardo Conesa
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Ana Rodríguez-Campello
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Jaume Capellades
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - María P García-Arnillas
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Juan L Fernández-Candil
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Carla Avellaneda-Gómez
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Eva Giralt-Steinhauer
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Jordi Jiménez-Conde
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Carolina Soriano-Tárraga
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Gloria Villalba-Martínez
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Rosa M Vivanco-Hidalgo
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Elio Vivas
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| | - Angel Ois
- From Servei de Neurologia (J.R., E.C.-G., A.R.-C., C.A.-G., E.G.-S., J.J.-C., C.S.-T., R.M.V.-H., A.O.), Departament J Merland de Neuroangiografia Terapèutica (L.G., E.V.), Servei de Neurocirurgia (G.C., G.V.-M.), Servei de Neuroradiologia (J.C.), Servei de Medicina Intensiva (M.P.G.-A.), and Servei d'Anestèsia i Reanimació (J.L.F.-C.), IMIM-Hospital del Mar, Barcelona; and Departament de Medicina (J.R., E.C.-G., A.R.-C., A.O.), Universitat Autònoma de Barcelona i DCEXS-Universitat Pompeu Fabra, Spain
| |
Collapse
|
14
|
Chai CL, Pyeong Jeon J, Tsai YH, Whittaker P, Macdonald RL, Lindgren AE, Ayling OG, Acioly MA, Cohen-Gadol A, Huang YH. Endovascular Intervention Versus Surgery in Ruptured Intracranial Aneurysms in Equipoise. Stroke 2020; 51:1703-1711. [DOI: 10.1161/strokeaha.120.028798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Chung Liang Chai
- From the School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, United Kingdom (C.L.C., P.W.)
- Department of Neurosurgery, Yee Zen General Hospital, Taoyuan, Taiwan (C.L.C.)
| | - Jin Pyeong Jeon
- Institute of New Frontier Stroke Research, Chuncheon, Republic of Korea (J.P.J.)
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Republic of Korea (J.P.J.)
- Genetic and Research Incorporation, Chuncheon, Republic of Korea (J.P.J.)
| | - Yi-Hsin Tsai
- Neurointensive Care Unit, Division of Neurosurgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan (Y.-H.T.)
| | - Paula Whittaker
- From the School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, United Kingdom (C.L.C., P.W.)
| | - R. Loch Macdonald
- Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, ON, Canada (R.L.M.)
| | - Antti E. Lindgren
- Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland (A.E.L.)
| | - Oliver G.S. Ayling
- Division of Neurosurgery, The University of British Columbia, Vancouver, Canada (O.G.S.A.)
| | - Marcus André Acioly
- Universidade Federal Fluminense, Division of Neurosurgery, Rio de Janeiro, Brazil (M.A.A.)
- Universidade Federal do Rio de Janeiro, Brazil (M.A.A.)
| | - Aaron Cohen-Gadol
- Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis (A.C.-G.)
| | | |
Collapse
|
15
|
Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Nakaji P, Karis JP, Wallace RC. Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg 2019; 132:771-776. [PMID: 30849758 DOI: 10.3171/2018.8.jns181846] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/21/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors present the 10-year results of the Barrow Ruptured Aneurysm Trial (BRAT) for saccular aneurysms. The 1-, 3-, and 6-year results of the trial have been previously reported, as have the 6-year results with respect to saccular aneurysms. This final report comparing the safety and efficacy of clipping versus coiling is limited to an analysis of those patients presenting with subarachnoid hemorrhage (SAH) from a ruptured saccular aneurysm. METHODS In the study, 362 patients had saccular aneurysms and were randomized equally to the clipping and the coiling cohorts (181 each). The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. The extent of aneurysm obliteration was adjudicated by a nontreating neuroradiologist. RESULTS There was no statistically significant difference in poor outcome (mRS score > 2) or deaths between these 2 treatment arms during the 10 years of follow-up. Of 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. After the initial hospitalization, 2 of 241 (0.8%) clipped saccular aneurysms and 23 of 115 (20%) coiled saccular aneurysms required retreatment (p < 0.001). At the 10-year follow-up, 93% (50/54) of the clipped aneurysms were completely obliterated, compared with only 22% (5/23) of the coiled aneurysms (p < 0.001). Two patients had documented rebleeding, both died, and both were in the assigned and treated coiled cohort (2/83); no patient in the clipped cohort (0/175) died (p = 0.04). In 1 of these 2 patients, the hemorrhage was not from the target aneurysm but from an incidental basilar artery aneurysm, which was coiled at the same time. CONCLUSIONS There was no significant difference in clinical outcomes between the 2 assigned treatment groups as measured by mRS outcomes or deaths. Clinical outcomes in the patients with posterior circulation aneurysms were better in the coiling group at 1 year, but after 1 year this difference was no longer statistically significant. Rates of complete aneurysm obliteration and rates of retreatment favored patients who actually underwent clipping compared with those who underwent coiling.Clinical trial registration no.: NCT01593267 (clinicaltrials.gov).
Collapse
Affiliation(s)
| | | | | | | | - Nancy K Hills
- Departments of3Neurology and.,4Epidemiology and Biostatistics, University of California, San Francisco, California
| | | | - John P Karis
- 5Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert C Wallace
- 5Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| |
Collapse
|
16
|
Kumar G, Dumitrascu OM, Chiang CC, O'Carroll CB, Alexandrov AV. Prediction of Delayed Cerebral Ischemia with Cerebral Angiography: A Meta-Analysis. Neurocrit Care 2019; 30:62-71. [PMID: 29998428 DOI: 10.1007/s12028-018-0572-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECT Cerebral catheter angiography is the gold standard for diagnosing cerebral artery vasospasm (vasospasm) in aneurysmal subarachnoid hemorrhage (SAH). We have previously published a meta-analysis of prediction of delayed cerebral ischemia (DCI) from transcranial Doppler (TCD) evidence of vasospasm. Analogous data relating to prediction of DCI have not been previously collated for cerebral angiography nor reconciled against TCD. METHODS We searched PUBMED, the Cochrane database, and clinicaltrials.gov for studies that used cerebral angiography for diagnosis of vasospasm and evaluated DCI in patients with SAH. We performed a random-effects meta-analysis of prediction of DCI with cerebral angiography, reconciling its accuracy against that of TCD. We also report quality of evidence for the value of cerebral angiography and TCD in SAH based on pooled data from our meta-analyses. RESULTS A total of 15 studies (n = 5463) were included in the meta-analysis. Sensitivity (SN), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of cerebral angiography for prediction of DCI are 57, 68, 32, and 90%. These metrics for TCD, based on our previous meta-analysis, are 90, 71, 57, and 92%. We report that test accuracy estimates are "moderate" for TCD and "low" for angiography based on pooled data from our meta-analyses. CONCLUSION TCD evidence of vasospasm is a better predictor of DCI than angiographic vasospasm. Future comparative effectiveness studies can better define the value of these diagnostic tools in patients with SAH.
Collapse
Affiliation(s)
- Gyanendra Kumar
- Division of Cerebrovascular Diseases, Department of Neurology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Oana M Dumitrascu
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Chia-Chun Chiang
- Division of Cerebrovascular Diseases, Department of Neurology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Cumara B O'Carroll
- Division of Cerebrovascular Diseases, Department of Neurology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
17
|
Lindgren A, Vergouwen MDI, van der Schaaf I, Algra A, Wermer M, Clarke MJ, Rinkel GJE. Endovascular coiling versus neurosurgical clipping for people with aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2018; 8:CD003085. [PMID: 30110521 PMCID: PMC6513627 DOI: 10.1002/14651858.cd003085.pub3] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Around 30% of people who are admitted to hospital with aneurysmal subarachnoid haemorrhage (SAH) will rebleed in the initial month after the haemorrhage if the aneurysm is not treated. The two most commonly used methods to occlude the aneurysm for prevention of rebleeding are microsurgical clipping of the neck of the aneurysm and occlusion of the lumen of the aneurysm by means of endovascular coiling. This is an update of a systematic review that was previously published in 2005. OBJECTIVES To compare the effects of endovascular coiling versus neurosurgical clipping in people with aneurysmal SAH on poor outcome, rebleeding, neurological deficit, and treatment complications. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (March 2018). In addition, we searched CENTRAL (2018, Issue 2), MEDLINE (1966 to March 2018), Embase (1980 to March 2018), US National Institutes of Health Ongoing Trials Register (March 2018), and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (last searched March 2018). We also contacted trialists. SELECTION CRITERIA We included randomised trials comparing endovascular coiling with neurosurgical clipping in people with SAH from a ruptured aneurysm. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, and assessed trial quality and risk of bias using the GRADE approach. We contacted trialists to obtain missing information. We defined poor outcome as death or dependence in daily activities (modified Rankin scale 3 to 6 or Glasgow Outcome Scale (GOS) 1 to 3). In the special worst-case scenario analysis, we assumed all participants in the group with better outcome with missing follow-up information had a poor outcome and those in the other group with missing data a good outcome. MAIN RESULTS We included four randomised trials involving 2458 participants (range per trial: 20 to 2143 participants). Evidence is mostly based on the largest trial. Most participants were in good clinical condition and had an aneurysm on the anterior circulation. None of the included trials was at low risk of bias in all domains. One trial was at unclear risk in one domain, two trials at unclear risk in three domains, and one trial at high risk in one domain.After one year of follow-up, 24% of participants randomised to endovascular treatment and 32% of participants randomised to the surgical treatment group had poor functional outcome. The risk ratio (RR) of poor outcome (death or dependency) for endovascular coiling versus neurosurgical clipping was 0.77 (95% confidence interval (CI) 0.67 to 0.87; 4 trials, 2429 participants, moderate-quality evidence), and the absolute risk reduction was 7% (95% CI 4% to 11%). In the worst-case scenario analysis for poor outcome, the RR for endovascular coiling versus neurosurgical clipping was 0.80 (95% CI 0.71 to 0.91), and the absolute risk reduction was 6% (95% CI 2% to 10%). The RR of death at 12 months was 0.80 (95% CI 0.63 to 1.02; 4 trials, 2429 participants, moderate-quality evidence). In a subgroup analysis of participants with an anterior circulation aneurysm, the RR of poor outcome was 0.78 (95% CI 0.68 to 0.90; 2 trials, 2157 participants, moderate-quality evidence), and the absolute risk decrease was 7% (95% CI 3% to 10%). In subgroup analysis of those with a posterior circulation aneurysm, the RR was 0.41 (95% CI 0.19 to 0.92; 2 trials, 69 participants, low-quality evidence), and the absolute decrease in risk was 27% (95% CI 6% to 48%). At five years, 28% of participants randomised to endovascular treatment and 32% of participants randomised to surgical treatment had poor functional outcome. The RR of poor outcome for endovascular coiling versus neurosurgical clipping was 0.87 (95% CI 0.75 to 1.01, 1 trial, 1724 participants, low-quality evidence). At 10 years, 35% participants allocated to endovascular and 43% participants allocated to surgical treatment had poor functional outcome. At 10 years RR of poor outcome for endovascular coiling versus neurosurgical clipping was 0.81 (95% CI 0.70 to 0.92; 1 trial, 1316 participants, low-quality evidence). The RR of delayed cerebral ischaemia at two to three months for endovascular coiling versus neurosurgical clipping was 0.84 (95% CI 0.74 to 0.96; 4 trials, 2450 participants, moderate-quality evidence). The RR of rebleeding for endovascular coiling versus neurosurgical clipping was 1.83 (95% CI 1.04 to 3.23; 4 trials, 2458 participants, high-quality evidence) at one year, and 2.69 (95% CI 1.50 to 4.81; 1 trial, 1323 participants, low-quality evidence) at 10 years. The RR of complications from intervention for endovascular coiling versus neurosurgical clipping was 1.05 (95% CI 0.44 to 2.53; 2 trials, 129 participants, low-quality evidence). AUTHORS' CONCLUSIONS The evidence in this systematic review comes mainly from one large trial, and long-term follow-up is available only for a subgroup of participants within that trial. For people in good clinical condition with ruptured aneurysms of either the anterior or posterior circulation the data from randomised trials show that, if the aneurysm is considered suitable for both neurosurgical clipping and endovascular coiling, coiling is associated with a better outcome. There is no reliable trial evidence that can be used directly to guide treatment in people with a poor clinical condition.
Collapse
Affiliation(s)
- Antti Lindgren
- Kuopio University HospitalDepartment of NeurosurgeryPuijonlaaksontie 2KuopioKuopioFinland70029
| | - Mervyn DI Vergouwen
- University Medical Center UtrechtDepartment of Neurology and NeurosurgeryPO Box 85500UtrechtNetherlands3508 GA
| | - Irene van der Schaaf
- University Medical Center UtrechtDepartment of RadiologyHeidelberglaan 100UtrechtNetherlands3508 GA
| | - Ale Algra
- University Medical Center UtrechtJulius Center for Health Sciences and Primary Care/Department of Neurology and NeurosurgeryPO Box 85500UtrechtNetherlands3508 GA
| | - Marieke Wermer
- Leiden University Medical CenterDepartment of NeurologyAlbinusdreef 2LeidenNetherlands2333 ZA
| | - Mike J Clarke
- Queen's University BelfastCentre for Public HealthInstitute of Clinical Sciences, Block B, Royal Victoria HospitalGrosvenor RoadBelfastNorthern IrelandUKBT12 6BJ
| | - Gabriel JE Rinkel
- University Medical Center UtrechtDepartment of Neurology and NeurosurgeryPO Box 85500UtrechtNetherlands3508 GA
| | | |
Collapse
|
18
|
Tölli A, Höybye C, Bellander BM, Johansson F, Borg J. The effect of time on cognitive impairments after non-traumatic subarachnoid haemorrhage and after traumatic brain injury. Brain Inj 2018; 32:1465-1476. [DOI: 10.1080/02699052.2018.1497203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Anna Tölli
- Dep. of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Charlotte Höybye
- Dep. of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Metabolism and Diabetology, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- Dep. of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Jörgen Borg
- Dep. of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
19
|
Ikawa F, Abiko M, Ishii D, Ohshita J, Matsushige T, Okazaki T, Sakamoto S, Hida E, Kobayashi S, Kurisu K. Analysis of outcome at discharge after aneurysmal subarachnoid hemorrhage in Japan according to the Japanese stroke databank. Neurosurg Rev 2017; 41:567-574. [PMID: 28821992 DOI: 10.1007/s10143-017-0894-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/07/2017] [Accepted: 08/10/2017] [Indexed: 11/30/2022]
Abstract
The outcomes at discharge for ruptured cerebral aneurysms after subarachnoid hemorrhage (SAH) were investigated using data from the Japanese stroke databank. Among 101,165 patients with acute stroke registered between 2000 and 2013, 4693 patients had SAH caused by ruptured saccular aneurysm. Of these, 3593 patients (1140 men and 2453 women; mean age 61.3 ± 13.7 years) were treated by surgical clipping (SC) and/or endovascular coiling (EC). The outcomes of modified Rankin scale (mRS) at discharge were compared between the SC and EC groups. There were 2666 cases in the SC group, 881 cases in the EC group, and 46 cases in the SC and EC group. The rates of poor outcome of mRS > 2 were 33.0 and 45.5% in the SC and EC groups (p < 0.05), respectively. Cases were selected using two types of criteria compatible with both treatments. Under the first compatible criteria, the rates of poor outcome of mRS > 2 were 18.9 and 24.8% in the SC and EC groups (p < 0.05), respectively. Under the second compatible criteria, the rates of poor outcome of mRS > 2 were 16.0 and 14.8% in the SC and EC groups (p = 0.22), respectively. No significant differences were found in clinical characteristics or outcomes between the two groups. Multivariate analysis of aneurysmal SAH revealed no significant risk for poor outcome associated with the treatment method. The present study was not a randomized controlled study, but no significant differences in mRS at discharge were found between SC and EC in the Japanese stroke databank.
Collapse
Affiliation(s)
- Fusao Ikawa
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Masaru Abiko
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Daizo Ishii
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Jyunpei Ohshita
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Toshinori Matsushige
- Department of Neurosurgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Takahito Okazaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Eisuke Hida
- Center for Integrated Medical Research, Educational Research Division, Central Clinical Facilities, Hiroshima University Hospital, Hiroshima, Japan
| | | | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| |
Collapse
|
20
|
Spetzler RF, Zabramski JM, McDougall CG, Albuquerque FC, Hills NK, Wallace RC, Nakaji P. Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg 2017; 128:120-125. [PMID: 28298031 DOI: 10.3171/2016.9.jns161301] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The 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. METHODS The 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. RESULTS Of 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). CONCLUSIONS In 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).
Collapse
Affiliation(s)
| | | | | | | | - Nancy K Hills
- 3Department of Neurology, University of California, San Francisco, California
| | - Robert C Wallace
- 2Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | | |
Collapse
|
21
|
Rosenwasser RH, Lang M, Tjoumakaris S, Jabbour P. Disruptive Innovation in Neurovascular Disease. Neurosurgery 2017; 64:78-82. [PMID: 28899063 DOI: 10.1093/neuros/nyx335] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/01/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michael Lang
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| |
Collapse
|
22
|
Kerezoudis P, McCutcheon BA, Murphy M, Rayan T, Gilder H, Rinaldo L, Shepherd D, Maloney PR, Hirshman BR, Carter BS, Bydon M, Meyer F, Lanzino G. Predictors of 30-day perioperative morbidity and mortality of unruptured intracranial aneurysm surgery. Clin Neurol Neurosurg 2016; 149:75-80. [DOI: 10.1016/j.clineuro.2016.07.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 07/01/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022]
|
23
|
Falk Delgado A, Andersson T, Falk Delgado A. 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. J Neurointerv Surg 2016; 9:264-277. [PMID: 27053705 DOI: 10.1136/neurintsurg-2016-012292] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/01/2016] [Accepted: 03/08/2016] [Indexed: 12/27/2022]
Abstract
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.
Collapse
Affiliation(s)
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Anna Falk Delgado
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
24
|
Azurmendi L, Degos V, Tiberti N, Kapandji N, Sanchez-Peña P, Sarrafzadeh A, Puybasset L, Turck N, Sanchez JC. Neopterin plasma concentrations in patients with aneurysmal subarachnoid hemorrhage: correlation with infection and long-term outcome. J Neurosurg 2015; 124:1287-99. [PMID: 26406798 DOI: 10.3171/2015.3.jns142212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high rates of mortality and morbidity. The main predictor for the poor outcome is the World Federation of Neurosurgical Societies (WFNS) scale. However, this scale does not take into account proinflammatory events, such as infection occurring after the aSAH, which could modify the long-term status of patients. The aim of this study was to evaluate neopterin as an inflammatory biomarker for outcome and infection prediction in aSAH patients. METHODS Plasma concentrations of neopterin were measured in 61 aSAH patients (22 male and 39 female; mean age [± SD] 52.8 ± 11.8 years) using a commercial ELISA kit. Samples were collected daily for 10 days. Outcome at 12 months was determined using the Glasgow Outcome Scale (GOS) and dichotomized as poor (GOS score 1, 2, or 3) or good (GOS score 4 or 5). Infection was determined by the presence of a positive bacterial culture. RESULTS Patients with poor outcome at 12 months had higher concentrations of neopterin than patients with good outcome. In the same way, patients who had an infection during the hospitalization had significantly higher concentrations of neopterin than patients without infection (p = 0.001). Moreover, neopterin concentrations were significantly (p < 0.008) elevated in infected patients 2 days before infection detection and antibiotic therapy. CONCLUSIONS Neopterin is an efficient outcome predictor after aSAH. Furthermore, it is able to differentiate between infected and uninfected patients as early as 2 days before clinical signs of infection, facilitating earlier antibiotic therapy and better management.
Collapse
Affiliation(s)
- Leire Azurmendi
- Department of Human Protein Sciences, University of Geneva, Geneva, Switzerland
| | - Vincent Degos
- Department of Anaesthesiology, Pitié-Salpêtrière University Hospital, Paris, France; and
| | - Natalia Tiberti
- Department of Human Protein Sciences, University of Geneva, Geneva, Switzerland
| | - Natacha Kapandji
- Department of Anaesthesiology, Pitié-Salpêtrière University Hospital, Paris, France; and
| | - Paola Sanchez-Peña
- Department of Anaesthesiology, Pitié-Salpêtrière University Hospital, Paris, France; and
| | - Asita Sarrafzadeh
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Germany
| | - Louis Puybasset
- Department of Anaesthesiology, Pitié-Salpêtrière University Hospital, Paris, France; and
| | - Natacha Turck
- Department of Human Protein Sciences, University of Geneva, Geneva, Switzerland
| | | |
Collapse
|
25
|
Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Russin JJ, Partovi S, Nakaji P, Wallace RC. The Barrow Ruptured Aneurysm Trial: 6-year results. J Neurosurg 2015; 123:609-17. [PMID: 26115467 DOI: 10.3171/2014.9.jns141749] [Citation(s) in RCA: 241] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors report the 6-year results of the Barrow Ruptured Aneurysm Trial (BRAT). This ongoing randomized trial, with the final goal of a 10-year follow-up, compares the safety and efficacy of surgical clip occlusion and endovascular coil embolization in patients presenting with subarachnoid hemorrhage (SAH) from a ruptured aneurysm. The 1- and 3-year results of this trial have been previously reported. METHODS In total, 500 patients with an SAH met the entry criteria and were enrolled in the study. Of these patients, 471 were randomly assigned to the treatments: 238 to surgical clipping and 233 to endovascular coiling. Six patients who died before treatment and 57 patients with nonaneurysmal SAHs were excluded, leaving a total of 408 patients who underwent clipping (209 assigned) or coiling (199 assigned). Whether to treat patients within the assigned group or to cross over patients to the other group was at the discretion of the treating physician; 38% (75/199) of the patients assigned to coiling were crossed over to clipping and 1.9% (4/209) assigned to clipping were crossed over to coiling. The outcome data were collected by a dedicated nurse practitioner. The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. Six years after randomization, 336 (82%) of 408 patients who had been treated were available for examination. RESULTS On the basis of an mRS score of > 2, and similar to the results at the 3-year follow-up, no significant difference in outcomes (p = 0.24) was detected between the 2 treatment groups. Complete aneurysm obliteration at 6 years was achieved in 96% (111/116) of the clipping group and in 48% (23/48) of the coiling group (p < 0.0001). In the period between the 3- and 6-year follow-ups, 3 additional patients assigned to coiling and none assigned to clipping received retreatment, for overall retreatment rates of 4.6% (13/280) for clipping and 16.4% (21/128) for coiling (p < 0.0001). When aneurysm location was considered, the 6-year results continued to match the previously reported results, with no difference in outcome for anterior circulation aneurysms at most time points. Of the anterior circulation aneurysms assigned to coiling treatment, 42% (70/168) were crossed over to clipping treatment. The outcomes for posterior circulation aneurysms continued to favor coiling. The randomization process was unexpectedly skewed, with 18 of 21 treated aneurysms of the posterior inferior cerebellar artery (PICA) being assigned to clipping, but even when PICA aneurysms were removed from the analysis, outcomes for the posterior circulation aneurysms still favored coiling. CONCLUSIONS Although BRAT was statistically underpowered to detect small differences, these results suggest little difference in outcome between the 2 treatments for anterior circulation aneurysms. This was not the case for the posterior circulation aneurysms, where coil embolization appeared to provide a sustained advantage over clipping. Aneurysm obliteration rates in BRAT were significantly lower and retreatment rates significantly higher in the patients undergoing coiling than in those undergoing clipping. However, despite the fact that retreatment rates were higher after coiling, no recurrent hemorrhages were known to have occurred in patients undergoing coiling in BRAT who were followed up for 6 years. Sufficient questions remain about the relative benefits of the 2 treatment modalities to warrant further well-designed randomized trials.
Collapse
Affiliation(s)
| | | | | | | | - Nancy K Hills
- Departments of 2 Neurology and.,Epidemiology and Biostatistics, University of California, San Francisco, California
| | | | - Shahram Partovi
- Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | | | - Robert C Wallace
- Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| |
Collapse
|
26
|
Liu Y, Li P, Hu X, Hu Y, Sun HG, Ma WC, Qiao F, He M, You C. Angiotensin-converting enzyme insertion/deletion gene polymorphism and risk of intracranial aneurysm in a Chinese population. J Int Med Res 2013; 41:1079-87. [PMID: 23847294 DOI: 10.1177/0300060513487625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective The relationship between angiotensin-converting enzyme (ACE) insertion/deletion (I/D) gene polymorphisms and intracranial aneurysm (IA) has been studied in Caucasian and Japanese populations. The present study aimed to investigate this association in a Chinese population. Methods Patients with confirmed IA and age- and sex-matched control subjects without evidence of IA were enrolled. ACE I/D gene polymorphisms were analysed using polymerase chain reaction–restriction fragment length polymorphism. Results A total of 220 patients with IA and 220 matched controls were enrolled. In the IA group, 64, 106 and 50 patients were of the II, ID and DD genotypes, respectively, compared with 44, 99 and 77 subjects in the control group. The ACE DD genotype and D allele frequencies were significantly lower in the IA group compared with the control group. There were no statistically significant differences in the site, shape, size and Fisher Grade of aneurysms between genotypes in patients with IA. Conclusion The ACE DD genotype may be a protective factor for IA in a Chinese population.
Collapse
Affiliation(s)
- Yi Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Peng Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiao Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao-Gen Sun
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei-Chao Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fei Qiao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Min He
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|