Stroke. 2006;37:572-573
Published online before print January 5, 2006,
doi: 10.1161/01.STR.0000199086.17521.98
(Stroke. 2006;37:572.)
© 2006 American Heart Association, Inc.
Endovascular Coiling Versus Neurosurgical Clipping for Patients With Aneurysmal Subarachnoid Hemorrhage
Irene van der Schaaf, MD;
Ale Algra, MD;
Marieke J. Wermer, MD;
Andrew Molyneux, MD;
Mike Clarke, Dphil;
Jan van Gijn, MD
Gabriël Rinkel, MD
From the Department of Radiology (I.vdS.), University Medical Centre, Utrecht, the Netherlands; the Julius Center for Health Sciences and Primary Care (A.A.), University Medical Centre, Utrecht, the Netherlands; the Department of Neurology (M.J.W., J.vG., G.R.), University Medical Center, Utrecht, the Netherlands; Neurovascular Research Unit (A.M.), University of Oxford, United Kingdom; and UK Cochrane Centre (M.C.), Oxford, UK.
Correspondence to Irene C. van der Schaaf, Department of Radiology E01.132, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail i.vanderschaaf{at}rrr.azu.nl
Section Editor: Graeme J. Hankey MD, FRCP
Key Words: aneurysm • subarachnoid hemorrhage
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Introduction
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Patients who have had an aneurysmal subarachnoid hemorrhage
(SAH) are at very high risk of rebleeding if the aneurysm is
not treated. The standard treatment for several decades has
been surgical clipping of the neck of the aneurysm. In recent
years, an alternative, the introduction of detachable coils
to occlude the aneurysm, has become more common.
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Objectives
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The goal was to compare the effects of endovascular coiling
versus neurosurgical clipping in patients with aneurysmal SAH.
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Methods
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Search Strategy
We searched the Cochrane Stroke Group Trials Register (last
searched in February 2005). In addition, we searched MEDLINE
(1966 to January 2004) and EMBASE (1980 to January 2004) and
contacted trialists.
Selection Criteria
We included randomized trials in which endovascular coiling of aneurysms was compared with neurosurgical clipping in patients with SAH who have proven aneurysm.
Data Collection and Analysis
Two authors independently extracted the data and assessed trial quality. Trialists were contacted to obtain missing information. The primary analyses were based on the intention-to-treat results of the individual trials, for "poor outcome" (death or dependence), and for case fatality.
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Results
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We identified 3 randomized trial
1,2 (Brilstra and Lusseveld
E, unpublished data, 2002). The trials included a total of 2272
patients (2143, 109, and 20 patients per trial, respectively).
Most of the patients were in good clinical condition and had
an aneurysm on the anterior circulation. After 1 year of follow-up,
the relative risk of poor outcome for coiling versus clipping
was 0.76 (95% CI, 0.67 to 0.88;
Figure). The absolute risk reduction
was 7% (95% CI, 4% to 11%). This means that if 14 (95% CI, 10
to 25) patients are coiled instead of clipped, 1 poor outcome
is prevented. In the worst case scenario analysis (in which,
for patients with missing follow-up data, those in the coil
strategy were assigned a poor outcome and those in the clip
strategy a good outcome) for poor outcome, the relative risk
for coiling versus clipping was 0.81 (95% CI, 0.70 to 0.92)
and the absolute risk reduction was 6% (95% CI, 2% to 10%).
For patients with anterior circulation aneurysm, the relative
risk of poor outcome was 0.78 (95% CI, 0.68 to 0.90), and the
absolute risk decrease was 7% (95% CI, 3% to 10%). For those
with a posterior circulation aneurysm, the relative risk was
0.41 (95% CI, 0.19 to 0.92), and the absolute decrease in risk
was 27% (95% CI, 6% to 48%).
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Conclusions
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The evidence comes mainly from 1 large trial. For patients in
good clinical condition with ruptured aneurysms of either the
anterior and posterior circulation, we have firm evidence that
if the aneurysm is considered suitable for surgical clipping
and endovascular treatment, coiling is associated with a better
outcome.
For patients in poor clinical grades, there is no reliable randomized evidence comparing the risks and benefits of coiling versus clipping. Because coiling is less invasive than surgery, also in patients with poor clinical condition, coiling seems the preferred option. A disadvantage of coiling is that aneurysms are more often incompletely treated (90% to 100% obliteration) and carry a risk for reopening. The long-term follow-up (>1 year after SAH) of coiled patients, with regard to renewed filling of the aneurysm, is an unknown but important issue that needs further study.
Received September 23, 2005;
accepted October 11, 2005.
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References
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- Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005; 366: 809–817.[CrossRef][Medline]
[Order article via Infotrieve]
- Koivisto T, Vanninen R, Hurskainen H, Saari T, Hernesniemi J, Vapalahti M. Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms. A prospective randomized study. Stroke. 2000; 31: 2369–2377.[Abstract/Free Full Text]
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Introduction
Objectives