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

Comparison of long-term clinical outcome after endovascular versus neurosurgical treatment of ruptured intracranial anterior circulation aneurysms: A single-centre experience

Introduction

In patients with anterior circulation aneurysmal Subarachnoid Haemorrhage (aSAH), endovascular coiling is currently practiced more frequently than neurosurgical clipping. However, despite multiple previous studies, it is still uncertain whether coiling is favourable in terms of long-term clinical outcome.

Research question

What is the effect of clipping versus coiling on long-term functional outcome of patients with an aSAH?

Material and methods

All anterior circulation aSAH patients (2012-2015) treated with clipping or coiling in two hospitals in the Netherlands were studied up to five years after treatment. Functional outcome, survival, retreatment- and complication rate were measured. Survival analysis was performed in both groups. A multivariable regression model with covariate adjustment was performed to investigate the likelihood of unfavourable outcome (modified Rankin Scale >2).

Results

Out of 204 patients, 75 patients were clipped (37%) and 129 received coiling (63%). Coiling had a higher retreatment rate compared to clipping (7.8% vs. 0.0%). Unfavourable outcome at six, 12, 24 and 60 months after treatment was higher for patients after clipping compared to coiling, but was not significant after correcting for clinical severity as represented by the WFNS grade. In 60 months, no difference in survival was found between clipping and coiling.

Discussion and conclusion

No differences between clipping and coiling in survival and long-term functional outcome have been found in this study. More research with prospective design and large cohorts is needed to identify possible differences between the two treatments.

The Role of Neurosurgical Techniques in Management of Acute and Chronic Stroke: A Comprehensive Literature Review

Stroke is a medical condition that results from a decreased or completely diminished supply of blood to the brain, and it is considered one of the major causes of morbidity and mortality globally. Stroke is categorized as ischemic and hemorrhagic stroke, both of which demand prompt and particular timely intervention. This extensive review is done to investigate the precise management of acute and chronic manifestations of stroke in relation to neurosurgical interventions, ultimately providing a thorough analysis regarding indications, procedures, outcomes, and complications that are associated with it. In this regard, a pervasive review of literature was carried out, which was primarily sourced from literature databases such as PubMed. This paper particularly outlines a sound relative analysis of anticipating the competence of each neurosurgical technique in use. Endovascular clot retrieval (ECR) has been particularly highlighted, as its effectiveness has been profoundly observed when selected as a treatment option within a time period of 6-24 hours following an ischemic stroke. In less than a time frame of 48 hours, decompressive hemicraniectomy (DH) is usually considered the most suitable treatment for cases of intracranial hypertension resulting from middle cerebral artery (MCA) infarction. Hemorrhages that occur due to ruptured aneurysms are most commonly dealt with clipping and neuroendovascular techniques. Additionally, considering that revascularization surgery is time-sensitive, the results can ultimately vary. Competent results have been linked with stereotactic surgery, which includes deep brain stimulation (DBS) and focused ultrasound ablation (FUSA), which are also famous for being minimally invasive in nature. However, the broader application of these techniques is hindered by the absence of established protocols. This review highlights the importance of timely interventions, advanced equipment, and precise medical protocols to optimize treatment outcomes.

Cerebral Perfusion Unveiled: A Comprehensive Review of Blood Pressure Management in Neurosurgical and Endovascular Aneurysm Interventions

This comprehensive review delves into the intricate dynamics of cerebral perfusion and blood pressure management within the context of neurosurgical and endovascular aneurysm interventions. The review highlights the critical role of maintaining a delicate hemodynamic balance, given the brain's susceptibility to fluctuations in blood pressure. Emphasizing the regulatory mechanisms of cerebral perfusion, particularly autoregulation, the study advocates for a nuanced and personalized approach to blood pressure control. Key findings underscore the significance of adhering to tailored blood pressure targets to mitigate the risks of ischemic and hemorrhagic complications in both neurosurgical and endovascular procedures. The implications for clinical practice are profound, calling for heightened awareness and precision in hemodynamic management. The review concludes with recommendations for future research, urging exploration into optimal blood pressure targets, advancements in monitoring technologies, investigations into long-term outcomes, and the development of personalized approaches. By consolidating current knowledge and charting a path for future investigations, this review aims to contribute to the continual enhancement of patient outcomes in the dynamic field of neurovascular interventions.

Thiopental and decompressive craniectomy as last-tier ICP-treatments in aneurysmal subarachnoid hemorrhage: is functional recovery within reach?

The study aimed to investigate the indication and functional outcome after barbiturates and decompressive craniectomy (DC) as last-tier treatments for elevated intracranial pressure (ICP) in aneurysmal subarachnoid hemorrhage (aSAH). This observational study included 891 aSAH patients treated at a single center between 2008 and 2018. Data on demography, admission status, radiology, ICP, clinical course, and outcome 1-year post-ictus were collected. Patients treated with thiopental (barbiturate) and DC were the main target group.Thirty-nine patients (4%) were treated with thiopental alone and 52 (6%) with DC. These patients were younger and had a worse neurological status than those who did not require these treatments. Before thiopental, the median midline shift was 0 mm, whereas basal cisterns were compressed/obliterated in 66%. The median percentage of monitoring time with ICP > 20 mmHg immediately before treatment was 38%, which did not improve after 6 h of infusion. Before DC, the median midline shift was 10 mm, and the median percentage of monitoring time with ICP > 20 mmHg before DC was 56%, which both significantly improved postoperatively. At follow-up, 52% of the patients not given thiopental or operated with DC reached favorable outcome, whereas this occurred in 10% of the thiopental and DC patients.In summary, 10% of the aSAH cohort required thiopental, DC, or both. Thiopental and DC are important integrated last-tier treatment options, but careful patient selection is needed due to the risk of saving many patients into a state of suffering.

A cases series of endovascular and microsurgical combined treatment of intracranial aneurysms

OBJECTIVE

Our scientific paper is aimed at describing multimodal treatment of intracranial aneurysms represented by microsurgery and endovascular therapy.

PATIENTS, MATERIALS AND METHODS

We report four cases of intracranial aneurysms treated in our Department of Neurosurgery by microsurgery (clipping) and endovascular treatment (coiling), through the joint efforts of a team of highly skilled neurosurgeons.

RESULTS

Mixed treatment has been imposed by the complications we were presented with, resulting from either of the two surgical methods employed.

CONCLUSIONS

Although endovascular surgery is considered a newer treatment method, favored by many practitioners, and preferred by patients, there are situations where open surgery is still required. There are certain situations were using one of the surgical methods fails and a complementary procedure is required for a secure and successful treatment. The cases reported here will demonstrate the utility of combining the two procedures.

A cost-utility analysis comparing endovascular coiling to neurosurgical clipping in the treatment of aneurysmal subarachnoid haemorrhage

Endovascular coiling (EC) has been identified in systematic reviews and meta-analyses to produce more favourable clinical outcomes in comparison to neurosurgical clipping (NC) when surgically treating a subarachnoid haemorrhage from a ruptured aneurysm. Cost-effectiveness analyses between both interventions have been done, but no cost-utility analysis has yet been published. This systematic review aims to perform an economic analysis of the relative utility outcomes and costs from both treatments in the UK. A cost-utility analysis was performed from the perspective of the National Health Service (NHS), over a 1-year analytic horizon. Outcomes were obtained from the randomised International Subarachnoid Aneurysm Trial (ISAT) and measured in terms of the patient's modified Rankin scale (mRS) grade, a 6-point disability scale that aims to quantify a patient's functional outcome following a stroke. The mRS score was weighted against the Euro-QoL 5-dimension (EQ-5D), with each state assigned a weighted utility value which was then converted into quality-adjusted life years (QALYs). A sensitivity analysis using different utility dimensions was performed to identify any variation in incremental cost-effectiveness ratio (ICER) if different input variables were used. Costs were measured in pounds sterling (£) and discounted by 3.5% to 2020/2021 prices. The cost-utility analysis showed an ICER of - £144,004 incurred for every QALY gained when EC was utilised over NC. At NICE's upper willingness-to-pay (WTP) threshold of £30,000, EC offered a monetary net benefit (MNB) of £7934.63 and health net benefit (HNB) of 0.264 higher than NC. At NICE's lower WTP threshold of £20,000, EC offered an MNB of £7478.63 and HNB of 0.374 higher than NC. EC was found to be more 'cost-effective' than NC, with an ICER in the bottom right quadrant of the cost-effectiveness plane-indicating that it offers greater benefits at lower costs. This is supported by the ICER being below the NICE's threshold of £20,000-£30,000 per QALY, and both MNB and HNB having positive values (> 0).

Ruptured Intracranial Aneurysm Presenting as Isolated Acute Subdural Hemorrhage

Ruptured intracranial aneurysms are often associated with serious neurologic sequelae, often as a result of subarachnoid or intraparenchymal hemorrhage. Less commonly, ruptured intracranial aneurysms can lead to subdural hemorrhage. However, the characteristic clinical presentation and optimal treatment of associated subdural hemorrhage are unclear due to the paucity of such cases that exist in the current literature. Affected patients may complain of nonspecific symptoms such as headaches, nausea, and confusion. Because of the severity of the disease, rapid diagnosis and intervention is required to lower the high morbidity and mortality rates. Commonly used treatment options include endovascular coiling and microsurgical clipping. Neuroendovascular surgery is often preferred, especially in aneurysms not amenable to surgical clipping, in poor surgical candidates, and cases with endovascularly favorable anatomy. The authors present the case of a patient who came to the hospital with ischemic stroke-like symptoms and was found to have a ruptured posterior communicating artery (PCoA) aneurysm and associated acute subdural hematoma (SDH) without obvious subarachnoid hemorrhage (SAH). Endovascular coiling of the aneurysm was performed successfully the following craniotomy for SDH evacuation, and the patient was discharged to a rehabilitation facility

Does establishing a neurovascular unit improve the outcome after surgical clipping for aneurysmal subarachnoid hemorrhage? Results from a 5-year observational study in Kuwait

Background:

Failure to prevent rebleeding after cerebral subarachnoid hemorrhage (SAH) is the most frequent reason for high morbidity and mortality of aneurysmal SAH. Our study aims to identify the outcome after surgical clipping of aneurysmal SAH before and after the establishment of the neurovascular unit. The clarifications of the positive turnover in the outcome will be discussed.

Methods:

A retrospective cohort analysis was carried out on our experience with a controlled group of patients who underwent clipping for ruptured cerebral aneurysms (n = 61) from January 2015 to December 2019. A modified Rankin scale (mRS) was used to determine the outcome after 6 months of follow-up.

Results:

The median mRS score (i.e., outcome) on admission was 4, whereas it was with a median score of 2 six months after clipping (P ≤ 0.001). Overall, the cases with a good outcome were 63.9% of the sample, while the poor outcome conditions were 36.1%. The most cases with an improved outcome were after introducing the neurovascular unit, representing a transition of aneurysmal clipping practice in our center. The good outcome was changed from 42% to 76.7%, and the poor outcome was changed from 58% to 23.3% (P = 0.019). The crude mortality rate was similar to the rate worldwide (18%), with a noticeable decrease after organizing a neurovascular subspecialty.

Conclusion:

The outcome after clipping of ruptured SAH can be largely affected by the surgeon’s experience and postoperative intensive care. Organizing a neurovascular team is one of the major factors to achieve good outcomes.

The Woven EndoBridge device for ruptured intracranial aneurysms: international multicenter experience and updated meta-analysis

PURPOSE

The Woven EndoBridge (WEB) can be used to treat wide-necked aneurysms without antiplatelet medications, suggesting it may have advantages in the setting of aneurysmal subarachnoid hemorrhage (aSAH). The goal was assessment of safety and efficacy of WEB in aSAH given the delayed nature of aneurysmal thrombosis.

METHODS

An international retrospective analysis of patients with aSAH treated with WEB was conducted at 7 tertiary centers from 2016 to 2020. Outcomes included rates of rebleeding, retreatment, complications, and complete occlusion. Furthermore, a systematic review and meta-analysis was conducted from 2011 to 2020 assessing the same outcomes. All pooled event rates were calculated using a random effect model.

RESULTS

Consecutive patients with aSAH harbored 25 aneurysms that were treated with 29 WEB devices. The mean age was 53 years, and 65% were female. Zero experienced rebleeding, 2 were retreated, 2 experienced complications, 16 were completely occluded at 3 months, and 21 were completed occluded at 9-12 months. Meta-analysis of 309 WEB treatments for aSAH from 7 case series revealed 2.5% (95% CI 1-5%) had rebleeding, 9% (95% CI 4-17%) were retreated, 17% (95% CI 10-30%) had complications, and 61% (95% CI 51-71%) were completely occluded at 3-6 months.

CONCLUSION

WEB embolization in the setting of aSAH provides similar protection against rebleeding with comparable retreatment rates to traditional approaches. However, there is a higher rate of incomplete radiographic occlusion and operative complications compared to WEB embolization of unruptured aneurysms. Long-term prospective studies are needed to fully delineate the role of WEB embolization in aSAH.

Endovascular management of large and giant intracranial aneurysms: Experience from a tertiary care neurosurgery institute in India

Objective

With the development of endovascular technique and devices, large and giant intracranial aneurysms are increasingly being managed by this less invasive method. Here we discuss our experience on managing such aneurysms via endovascular technique.

Methods

Retrospective data on 42 patients with large and giant intracranial aneurysms managed by endovascular techniques between September 2015 to December 2017 at our neurosurgery institute were included in this analysis.

Results

There were a total 42 patients with 9 giant and 33 large aneurysms in this study. Eight aneurysms were treated by parent vessel occlusion, 22 aneurysms with coils and rest 12 aneurysms were treated with stent assisted coiling. Following the procedure, Raymond class I occlusion was accomplished in 31 (73.8%) patients while class Ⅱ in 9 (21.4%) and class Ⅲ in 2 (4.8%) patients. Overall morbidity and mortality were 9.5% and 14.3% respectively and favorable outcome was seen in 80.9% patients. Significant correlation was observed with clinical outcome and initial neurological status.

Conclusions

The study indicates that endovascular intervention is a safe and effective method in managing large and giant intracranial aneurysms with lesser morbidity and mortality.

Risk Factors for Prognosis in Elderly Patients with Severe Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study

INTRODUCTION

To investigate the risk factors affecting the prognosis of elderly patients with severe aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

Forty-nine elderly patients with severe aSAH (Hunt and Hess [H-H] grade III-V) were enrolled in this retrospective study. Follow-up was conducted with patients 30 days after discharge using the Glasgow Outcome Scale (GOS), on which scores of 1-3 indicated a poor outcome (n = 32) and scores of 4-5 indicated a good outcome (n = 17). The patients' general information (gender, age, presence of hypertension, diabetes, or coronary atherosclerotic heart disease, location of ruptured aneurysm, and H-H grade) and complications (cerebral vasospasm, new cerebral infarction, pulmonary infection, liver dysfunction, hypoalbuminemia, anemia, and electrolyte disturbance) were recorded, and comparison between the different outcome groups was undertaken. Univariate analysis was used to analyze the factors associated with different outcomes, and multivariate logistic regression analysis was used to determine the factors that lead to poor outcomes.

RESULTS

The incidence of all complications increased in patients with higher H-H grades, but without statistical significance (P > 0.05). There was no statistically significant difference between the two outcome (poor and good) groups in general information and complications (all P > 0.05), with the exception of different H-H grades (P < 0.05). H-H grade was a statistically significant risk factor for poor outcomes in elderly patients with severe aSAH (OR 11.627, 95% CI 2.475-55.556, P = 0.002).

CONCLUSION

H-H grade is an independent factor related to the prognosis of elderly patients with severe aSAH.

Endovascular coiling versus surgical clipping for aneurysmal subarachnoid hemorrhage: A meta-analysis of randomized controlled trials

Background:

Aneurysmal subarachnoid hemorrhage is a relatively rare cause of stroke, carrying a bad prognosis of mortality and disability. The current standard procedure, neurosurgical clipping, has failed to achieve satisfactory outcomes. Therefore, endovascular detachable coils have been tested as an alternative. This meta-analysis was aimed to compare the outcomes of surgical clipping and endovascular coiling in aneurysmal subarachnoid hemorrhage.

Materials and Methods:

Relevant randomized trials up to June 2018 were identified from Medline, Central, and Web of Science. Data for poor outcomes (Modified Rankin Scale [mRS] scores 3 to 6) at 2–3 months, 1 year, and 3–5 years were extracted and analyzed as odds ratios (ORs) with 95% confidence intervals (CIs), using RevMan software.

Results:

Five studies (2780: 1393 and 1387 patients in the coiling and clipping arms, respectively) were included in the current analysis. The overall effect estimate favored endovascular coiling over surgical clipping in terms of reducing poor outcomes (death or dependency, mRS > 2) at 1 year (OR = 0.67, 95% CI: 0.57–0.79) and 3–5 years (OR = 0.8, 95% CI: 0.67–0.96). Moreover, coiling was associated with a significantly lower rate of cerebral ischemia (OR = 0.37, 95% CI: 0.16–0.86). Postprocedural mortality (OR = 0.79, 95% CI: 0.6–1.05) and rebleeding (OR = 1.15, 95% CI: 0.75–1.78) rates were comparable between the two groups. However, technical failure was significantly more common with coiling interventions than with clipping surgeries (OR = 2.84, 95% CI: 1.86–4.34).

Conclusion:

Our analysis suggests that coiling can be a better alternative to clipping in terms of surgical outcomes. Further improvements in the coiling technique and training may improve the outcomes of this procedure.