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Nasra M, Maingard JT, Hall J, Mitreski G, Kuan Kok H, Smith PD, Russell JH, Jhamb A, Brooks DM, Asadi H. Clipping versus coiling: A critical re-examination of a decades old controversy. Interv Neuroradiol 2024; 30:86-93. [PMID: 36017537 PMCID: PMC10956463 DOI: 10.1177/15910199221122854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Two major studies, The International Subarachnoid Aneurysm Trial and the Barrow Ruptured Aneurysm Trial, compare the long-term outcomes of clipping and coiling. Although these demonstrated coiling's initial benefits, rebleeding and retreatment rates as well as converging patient outcomes sparked controversy regarding its durability. This article will critically examine the available evidence for and against clipping and coiling of intracranial aneurysms. Critics of endovascular treatment state that the initial benefit seen with endovascular coiling decreases over the duration of follow-up and eventually functional outcomes of both treatment modalities are similar. Combined with the increased rate of retreatment and rebleeding, these trials reveal that coiling is not as durable and not as effective as a long-term treatment compared to clipping. Also, due to the cost of devices following endovascular treatment and prolonged hospitalization following clipping, the financial burden has been considered controversial. SUMMARY/KEY MESSAGES Short-term outcomes reveal better morbidity and mortality outcomes following coiling. Despite the higher rates of retreatment and rebleeding with coiling, there was no significant change in functional outcomes following retreatment. Furthermore, examining more recent trials reveals a decreased rate of recurrence and rebleeding with improved technology and expertise. Functional outcomes deteriorate for both cohorts over time while recent results revealed improved long-term cognitive outcomes and levels of health-related quality of life after coiling in comparison to clipping. The expense of longer hospital stays following clipping must be balanced against the expense of endovascular devices in coiling.
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Affiliation(s)
| | - Julian Tam Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
| | - Jonathan Hall
- Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Goran Mitreski
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service, Northern Hospital, Epping, Victoria, Australia
| | - Paul D. Smith
- Department of Neurosurgery, St Vincent's Hospital, Fitzroy, Victoria, Melbourne, Australia
- Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Jeremy H. Russell
- Department of Neurosurgery, Austin Health, Heidelberg, Victoria, Australia
| | - Ashu Jhamb
- Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Duncan Mark Brooks
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
- School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
- School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
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Kappel AD, Nguyen HB, Frerichs KU, Patel NJ, Aziz-Sultan MA, Du R. Randomized Clinical Trials in Cerebrovascular Neurosurgery From 2018 to 2022. Cureus 2024; 16:e52397. [PMID: 38361699 PMCID: PMC10869144 DOI: 10.7759/cureus.52397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
There has been an exponential increase in randomized controlled trials (RCTs) on cerebrovascular disease within neurosurgery. The goal of this study was to review, outline the scope, and summarize all phase 2b and phase 3 RCTs impacting cerebrovascular neurosurgery practice since 2018. We searched PubMed, MEDLINE, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases for relevant RCTs published between January 1, 2018, and July 1, 2022. We searched for studies related to eight major cerebrovascular disorders relevant to neurosurgery, including acute ischemic stroke, cerebral aneurysms and subarachnoid hemorrhage, intracerebral hemorrhage, subdural hematomas, cerebral venous thrombosis, arteriovenous malformations, Moyamoya disease and extracranial-intracranial bypass, and carotid and intracranial atherosclerosis. We limited our search to phase 2b or 3 RCTs related to cerebrovascular disorders published during the study period. The titles and abstracts of all relevant studies meeting our search criteria were included. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. From an initial total of 2,797 records retrieved from the database searches, 1,641 records were screened after duplicates and studies outside of our time period were removed. After screening, 511 available reports within our time period of interest were assessed for eligibility. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. We found 80 unique phase 2b or 3 RCTs that fit our criteria, with 165 topic-relevant articles published within the study period. Numerous RCTs in cerebrovascular neurosurgery have been published since 2018. Ischemic stroke, including mechanical thrombectomy and thrombolysis, accounted for a majority of publications, but there were large trials in intracerebral hemorrhage, subdural hemorrhage, aneurysms, subarachnoid hemorrhage, and cerebral venous thrombosis, among others. This review helps define the scope of the large RCTs published in the last four years to guide future research and clinical care.
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Affiliation(s)
- Ari D Kappel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | | | - Nirav J Patel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | - Rose Du
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
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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.
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Affiliation(s)
| | | | - Kumara Tini
- Department of Neurology, Universitas Udayana, Denpasar, Bali, Indonesia
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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.
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Abstract
Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA.
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
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Inter-rater reliability of the simplified Modified Rankin Scale as an outcome measure for treated cerebral aneurysm patients. Neurochirurgie 2022; 68:488-492. [PMID: 35662528 DOI: 10.1016/j.neuchi.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The modified Rankin scale (mRS) is commonly used as a clinical outcome measure in aneurysm trials, but inter-observer reliability in treated patients has not been tested. METHODS We reviewed the literature on inter-observer reliability studies of the mRS. Sixty patients with ruptured (n=47) or unruptured (n=13) aneurysms treated with endovascular methods (n=34) or surgical clipping (n=26) were independently evaluated by a neurosurgeon, a stroke neurologist, and a novice research assistant, and a simplified mRS score assigned. Results were analyzed using Gwet's AC1/2 reliability coefficients (KG). RESULTS No previous reports validating the reliability of the mRS in treated aneurysm patients were identified. Using the mRS 0-5, inter-rater agreement was almost perfect (KG=0.89 [0.86-0.93]). Agreement between raters remained almost perfect regardless of the rater's expertise. Agreement was almost perfect (KG=0.87 [0.77-0.96] when the mRS was dichotomized 0-2 vs 3-5, but fell to moderate when dichotomized 0-1 vs 2-5 (KG=0.59 (0.42-0.75). Agreement using the 0-2 vs 3-5 dichotomized mRS remained almost perfect for coiled (KG=0.90), clipped (KG=0.82), ruptured (KG=0.84), and unruptured (KG=0.95) aneurysms. Dichotomization of results at 0-1 vs 2-5 would have resulted in an (undesirable) significant difference in good outcomes between raters (P=.003), but not at 0-2 vs 3-5 (P=.52). CONCLUSION The simplified mRS appears to be a reliable clinical outcome measure for treated cerebral aneurysm patients. When needed, dichotomization is more reliable at mRS 0-2 vs 3-5 than at 0-1 vs 2-5. The simplified mRS is a promising tool in the functional assessment of aneurysm patients recruited in pragmatic care trials.
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Darsaut TE, Keough MB, Boisseau W, Findlay JM, Bojanowski MW, Chaalala C, Iancu D, Weill A, Roy D, Estrade L, Lejeune JP, Januel AC, Carlson AP, Sauvageau E, Al-Jehani H, Orlov K, Aldea S, Piotin M, Gaberel T, Gevry G, Raymond J. Middle Cerebral Artery Aneurysm Trial (MCAAT): A randomized care trial comparing surgical and endovascular management of MCA aneurysm patients. World Neurosurg 2021; 160:e49-e54. [PMID: 34971833 DOI: 10.1016/j.wneu.2021.12.083] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty. METHODS The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multi-center, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is 'Treatment Success': i) occlusion or exclusion of the aneurysm using the allocated treatment modality; ii) no intracranial hemorrhage during follow-up; iii) no retreatment of the target aneurysm during follow-up, iv) no residual aneurysm on angiographic follow-up and v) independence (mRS <3) at 1 year. The trial tests two versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared to endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1 year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377. CONCLUSION Patients with MCA aneurysms can be optimally managed within a care trial protocol.
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Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - William Boisseau
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, CHU de Lille, Hôpital Salengro, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, CHU de Lille, Hôpital Salengro, Lille, France
| | - Anne-Christine Januel
- Department of Interventional Neuroradiology, CHU de Toulouse, Hôpital Purpan, Toulouse, France
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida, USA
| | - Hosam Al-Jehani
- Department of Neurosurgery and Radiology, King Fahad University Hospital, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Kirill Orlov
- Endovascular Neurosurgery Research Center, Federal Center of Brain Research and Neurotechnologies of the Federal Medical Biological Agency of Russia, Moscow, Russia
| | - Sorin Aldea
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | | | - Guylaine Gevry
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
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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.
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Management of intracranial aneurysms in France: Place of microsurgery and demography of vascular neurosurgeons. Neurochirurgie 2021; 67:414-419. [PMID: 33766562 DOI: 10.1016/j.neuchi.2021.03.003] [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] [Received: 11/17/2020] [Revised: 02/03/2021] [Accepted: 03/06/2021] [Indexed: 01/18/2023]
Abstract
STUDY DESIGN Observational retrospective survey-based study. INTRODUCTION Intracranial aneurysms (IA) can be treated with microsurgery or by endovascular treatments (EVT). EVT have taken an increasingly important part in IA management; the ability of neurosurgical teams to perform such surgery as well as the quality of their training is being questioned. We therefore wanted to assess the proportion of IA treated by microsurgery in France, the demography and caseload of surgeons trained in vascular neurosurgery. METHODOLOGY A 60-question survey was sent to the 34 French neurosurgical centers treating IA. Twenty-seven questions dealt with the demography of neurovascular surgeons and caseload. Descriptive data are reported here. RESULTS Twenty-seven centers answered, giving us a response rate of 79.4%. A total of 209 neurosurgeons worked in these centers. Forty-six neurosurgeons were designated as referents in vascular neurosurgery, 47% of them were under 45 years old. Among the centers, 96.3% had at least one surgeon that was a referent in neurovascular surgery. A total of 88 surgeons performed IA surgery, but only 11 operated more than 20 IA per year. Two thousand four hundred and thirty seven unruptured IA were treated every year in these centers, 25% of which by microsurgery. A total of 2727 ruptured IA were treated in these centers, of which 15% were treated by microsurgery. The most common indications for microsurgical treatment of IA were: middle cerebral artery aneurysms, wide-neck intracranial aneurysms, and giant intracranial aneurysms, as well as aneurysms associated with a hematoma for the ruptured ones. CONCLUSION Demography of vascular neurosurgeons remains favorable, with a referent neurosurgeon in most centers, who, in half of the cases, is a young practitioner. The percentage of microsurgery in the treatment of IA is low, especially for ruptured ones. The most frequently operated types of intracranial aneurysm correspond to good practice recommendations.
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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.
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Darsaut TE, Keough MB, Sagga A, Chan VKY, Diouf A, Boisseau W, Magro E, Kotowski M, Roy D, Weill A, Iancu D, Bojanowski MW, Chaalala C, Bilocq A, Estrade L, Lejeune JP, Bricout N, Scholtes F, Martin D, Otto B, Findlay JM, Chow MM, O'Kelly CJ, Ashforth RA, Rempel JL, Lesiuk H, Sinclair J, Altschul DJ, Arikan F, Guilbert F, Chagnon M, Farzin B, Gevry G, Raymond J. Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison. World Neurosurg 2021; 149:e521-e534. [PMID: 33556601 DOI: 10.1016/j.wneu.2021.01.142] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials. METHODS Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded. RESULTS There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02-0.19) for clipping and 13/48 (27%; 95% CI, 0.17-0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09-0.33) cases, and 8/33 (24%; 95% CI, 0.13-0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60-0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22-0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54-0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36-0.70) patients with RA allocated coiling. CONCLUSIONS Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.
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Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Abdelaziz Sagga
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Vivien K Y Chan
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Ange Diouf
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - William Boisseau
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Elsa Magro
- Service of Neurosurgery, CHU Cavale Blanche, InsermUMR 1101 LaTIM, Brest, France
| | - Marc Kotowski
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniela Iancu
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Service of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Chiraz Chaalala
- Service of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Bilocq
- Centre Hospitalier Régional de Trois-Rivières Service of Neurosurgery, Trois-Rivières, Quebec, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Felix Scholtes
- Department of Neurosurgery, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Didier Martin
- Department of Neurosurgery, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Bernard Otto
- Division of Medical Imaging, Department of Medical Physics, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael M Chow
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Cian J O'Kelly
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Robert A Ashforth
- Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Jeremy L Rempel
- Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Howard Lesiuk
- Section of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - John Sinclair
- Section of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - David J Altschul
- Department of Neurological Surgery and Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Fuat Arikan
- Department of Neurosurgery and Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francois Guilbert
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, Université de Montréal, Montréal, Quebec, Canada
| | - Behzad Farzin
- Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Guylaine Gevry
- Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jean Raymond
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Darsaut T, Raymond J. Experience using pragmatic care trials to guide neurovascular practice under uncertainty. Neurochirurgie 2020; 66:423-428. [DOI: 10.1016/j.neuchi.2020.06.136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/03/2020] [Accepted: 06/19/2020] [Indexed: 01/04/2023]
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Darsaut TE, Raymond J. Practicing outcome-based medical care using pragmatic care trials. Trials 2020; 21:899. [PMID: 33121523 PMCID: PMC7599099 DOI: 10.1186/s13063-020-04829-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 10/17/2020] [Indexed: 12/23/2022] Open
Abstract
The current separation between medical research and care is an obstacle to essential aspects of good medical practice: the verification that care interventions actually deliver the good outcomes they promise, and the use of scientific methods to optimize care under uncertainty. Pragmatic care trials have been designed to address these problems. Care trials are all-inclusive randomized trials integrated into care. Every item of trial design is selected in the best medical interest of participating patients. Care trials can eventually show what constitutes good medical practice based on patient outcomes. In the meantime, care trials give clinicians and patients the scientific methods necessary for optimization of medical care when no one really knows what to do.We report the progress of 9 randomized care trials that were used to guide the endovascular or surgical management of 1212 patients with acute stroke, intracranial aneurysms, and arteriovenous malformations in a single center in an elective or acute care context. Care trials were used to address long-standing dilemmas regarding rival medical, surgical, or endovascular management options or to offer innovative instead of standard treatments. The trial methodology, by replacing unrepeatable treatment decisions by 1:1 randomized allocation whenever reliable knowledge was not available, had an immediate impact, transforming unverifiable dogmatic medical practice into verifiable outcome-based medical care. We believe the approach is applicable to all medical or surgical domains, but widespread adoption may require the revision of many currently prevalent views regarding the role of research in clinical practice.
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Affiliation(s)
- Tim E. Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 - 112 Street, Edmonton, Alberta T6G 2B7 Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l’Université de Montréal – CHUM, 1000 Saint-Denis street, room D03-5462B, Montreal, QC H2X 0C1 Canada
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Darsaut TE, Raymond J. Letter to the Editor. Barrow Ruptured Aneurysm Trial 10-year results. J Neurosurg 2020; 133:1276-1277. [PMID: 32590356 DOI: 10.3171/2020.4.jns201372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tim E Darsaut
- 1University of Alberta Hospital, Edmonton, AB, Canada
| | - Jean Raymond
- 2Centre Hospitalier de l'Université de Montréal-CHUM, Montreal, QC, Canada
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van Donkelaar CE, Bakker NA, Birks J, Clarke A, Sneade M, Kerr RSC, Veeger NJGM, van Dijk JMC, Molyneux AJ. Impact of Treatment Delay on Outcome in the International Subarachnoid Aneurysm Trial. Stroke 2020; 51:1600-1603. [PMID: 32208844 DOI: 10.1161/strokeaha.120.028993] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- ISAT (International Subarachnoid Aneurysm Trial) demonstrated that 1 year after aneurysmal subarachnoid hemorrhage, coiling resulted in a significantly better clinical outcome than clipping. After 5 years, this difference did not reach statistical significance, but mortality was still higher in the clipping group. Here, we present additional analyses, reporting outcome after excluding pretreatment deaths. Methods- Outcome measures were death with or without dependency at 1 and 5 years after treatment, after exclusion of all pretreatment deaths. Treatment differences were assessed using relative risks (RRs). With sensitivity and exploratory analyses, the relation between treatment delay and outcome was analyzed. Results- After exclusion of pretreatment deaths, at 1-year follow-up coiling was favorable over clipping for death or dependency (RR, 0.77 [95% CI, 0.67-0.89]) but not for death alone (RR, 0.88 [95% CI, 0.66-1.19]). After 5 years, no significant differences were observed, neither for death or dependency (RR, 0.88 [95% CI, 0.77-1.02]) nor for death alone (RR, 0.82 [95% CI, 0.64-1.05]). Sensitivity analyses showed a similar picture. In good-grade patients, coiling remained favorable over clipping in the long-term. Time between randomization and treatment was significantly longer in the clipping arm (mean 1.7 versus 1.1 days; P<0.0001), during which 17 patients died because of rebleeding versus 6 pretreatment deaths in the endovascular arm (RR, 2.81 [95% CI, 1.11-7.11]). Conclusions- These additional analyses support the conclusion of ISAT that at 1-year follow-up after aneurysmal subarachnoid hemorrhage coiling has a better outcome than clipping. After 5 years, with pretreatment mortality excluded, the difference between coiling and clipping is not significant. The high number of pretreatment deaths in the clipping group highlights the importance of urgent aneurysm treatment to prevent early rebleeding.
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Affiliation(s)
- Carlina E van Donkelaar
- From the Department of Neurosurgery (C.E.v.D., N.A.B., J.M.C.v.D.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Nicolaas A Bakker
- From the Department of Neurosurgery (C.E.v.D., N.A.B., J.M.C.v.D.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Jacqueline Birks
- Center for Statistics in Medicine, Oxford, United Kingdom (J.B.)
| | - Alison Clarke
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford University Hospitals Foundation NHS Trust, United Kingdom (A.C., M.S., A.J.M.)
| | - Mary Sneade
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford University Hospitals Foundation NHS Trust, United Kingdom (A.C., M.S., A.J.M.)
| | - Richard S C Kerr
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, United Kingdom (R.S.C.K.)
| | - Nic J G M Veeger
- Department of Epidemiology (N.J.G.M.V.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - J Marc C van Dijk
- From the Department of Neurosurgery (C.E.v.D., N.A.B., J.M.C.v.D.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Andrew J Molyneux
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford University Hospitals Foundation NHS Trust, United Kingdom (A.C., M.S., A.J.M.)
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