1
|
Darsaut TE, Findlay JM, Bojanowski MW, Chalaala C, Iancu D, Roy D, Weill A, Boisseau W, Diouf A, Magro E, Kotowski M, Keough MB, Estrade L, Bricout N, Lejeune JP, Chow MMC, O'Kelly CJ, Rempel JL, Ashforth RA, Lesiuk H, Sinclair J, Erdenebold UE, Wong JH, Scholtes F, Martin D, Otto B, Bilocq A, Truffer E, Butcher K, Fox AJ, Arthur AS, Létourneau-Guillon L, Guilbert F, Chagnon M, Zehr J, Farzin B, Gevry G, Raymond J. A Pragmatic Randomized Trial Comparing Surgical Clipping and Endovascular Treatment of Unruptured Intracranial Aneurysms. AJNR Am J Neuroradiol 2023; 44:634-640. [PMID: 37169541 PMCID: PMC10249696 DOI: 10.3174/ajnr.a7865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/10/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND PURPOSE Surgical clipping and endovascular treatment are commonly used in patients with unruptured intracranial aneurysms. We compared the safety and efficacy of the 2 treatments in a randomized trial. MATERIALS AND METHODS Clipping or endovascular treatments were randomly allocated to patients with one or more 3- to 25-mm unruptured intracranial aneurysms judged treatable both ways by participating physicians. The study hypothesized that clipping would decrease the incidence of treatment failure from 13% to 4%, a composite primary outcome defined as failure of aneurysm occlusion, intracranial hemorrhage during follow-up, or residual aneurysms at 1 year, as adjudicated by a core lab. Safety outcomes included new neurologic deficits following treatment, hospitalization of >5 days, and overall morbidity and mortality (mRS > 2) at 1 year. There was no blinding. RESULTS Two hundred ninety-one patients were enrolled from 2010 to 2020 in 7 centers. The 1-year primary outcome, ascertainable in 290/291 (99%) patients, was reached in 13/142 (9%; 95% CI, 5%-15%) patients allocated to surgery and in 28/148 (19%; 95% CI, 13%-26%) patients allocated to endovascular treatments (relative risk: 2.07; 95% CI, 1.12-3.83; P = .021). Morbidity and mortality (mRS >2) at 1 year occurred in 3/143 and 3/148 (2%; 95% CI, 1%-6%) patients allocated to surgery and endovascular treatments, respectively. Neurologic deficits (32/143, 22%; 95% CI, 16%-30% versus 19/148, 12%; 95% CI, 8%-19%; relative risk: 1.74; 95% CI, 1.04-2.92; P = .04) and hospitalizations beyond 5 days (69/143, 48%; 95% CI, 40%-56% versus 12/148, 8%; 95% CI, 5%-14%; relative risk: 0.18; 95% CI, 0.11-0.31; P < .001) were more frequent after surgery. CONCLUSIONS Surgical clipping is more effective than endovascular treatment of unruptured intracranial aneurysms in terms of the frequency of the primary outcome of treatment failure. Results were mainly driven by angiographic results at 1 year.
Collapse
Affiliation(s)
- T E Darsaut
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - J M Findlay
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | | | | | - D Iancu
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - D Roy
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Weill
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - W Boisseau
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Diouf
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - E Magro
- Service of Neurosurgery (E.M.), Centre Hospitalier Universitaire Cavale Blanche, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1101 LaTIM, Brest, France
| | - M Kotowski
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M B Keough
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - L Estrade
- Interventional Neuroradiology (L.E., N.B.)
| | - N Bricout
- Interventional Neuroradiology (L.E., N.B.)
| | - J-P Lejeune
- Service of Neurosurgery (J.-P.L.), Centre Hospitalier Universitaire de Lille, Lille, France
| | - M M C Chow
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - C J O'Kelly
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - J L Rempel
- Department of Surgery, and Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - R A Ashforth
- Department of Surgery, and Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - H Lesiuk
- Section of Neurosurgery (H.L., J.S.)
| | | | - U-E Erdenebold
- Department of Surgery, and Department of Medical Imaging (U.-E.E.), Section of Interventional Neuroradiology, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J H Wong
- Division of Neurosurgery (J.H.W.), Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - F Scholtes
- Departments of Neurosurgery (F.S., D.M.)
| | - D Martin
- Departments of Neurosurgery (F.S., D.M.)
| | - B Otto
- Medical Physics (B.O.), Division of Medical Imaging, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - A Bilocq
- Service of Neurosurgery (A.B., E.T.), Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Québec, Canada
| | - E Truffer
- Service of Neurosurgery (A.B., E.T.), Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Québec, Canada
| | - K Butcher
- Clinical Neurosciences (K.B.), Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - A J Fox
- Department of Medical Imaging (A.J.F.), University of Toronto, Toronto, Ontario, Canada
| | - A S Arthur
- Department of Neurosurgery (A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee
| | - L Létourneau-Guillon
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - F Guilbert
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montréal, Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montréal, Québec, Canada
| | - B Farzin
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
| | - G Gevry
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
| | - J Raymond
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
| |
Collapse
|
2
|
Raymond J, Létourneau-Guillon L, Darsaut TE, Findlay JM, Chow MM, Keough MB, Chan AM, Farzin B, Gevry G, Chagnon M, Zehr J. Reply. AJNR Am J Neuroradiol 2022; 43:E4. [PMID: 35241423 PMCID: PMC8910809 DOI: 10.3174/ajnr.a7454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J. Raymond
- Department of Radiology, Neuroradiology Service Centre Hospitalier de l’Université de Montréal (CHUM), Montreal Quebec, CanadaCHUM Research Centre, MontrealQuebec, Canada
| | - L. Létourneau-Guillon
- Department of Radiology, Neuroradiology Service Centre Hospitalier de l’Université de Montréal (CHUM), Montreal Quebec, CanadaCHUM Research Centre, MontrealQuebec, Canada
| | - T E Darsaut
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - J M Findlay
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - M M Chow
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - M B Keough
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | - A M Chan
- Department of Surgery, Division of Neurosurgery University of Alberta hospital, Mackenzie Health Sciences Center, EdmontonAlberta, Canada
| | | | - G Gevry
- CHUM Research Centre, MontrealQuebec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics Université de Montréal, Montreal Quebec, Canada
| | - J Zehr
- Department of Mathematics and Statistics Université de Montréal, Montreal Quebec, Canada
| |
Collapse
|
3
|
Darsaut TE, Derksen C, Farzin B, Keough MB, Fahed R, Boisseau W, Letourneau-Guillon L, Januel AC, Weill A, Roy D, Nguyen TN, Finitsis S, Gentric JC, Volders D, Carlson A, Chow MM, O'Kelly C, Rempel JL, Ashforth RA, Chagnon M, Zehr J, Findlay JM, Gevry G, Raymond J. Reliability of the Diagnosis of Cerebral Vasospasm Using Catheter Cerebral Angiography: A Systematic Review and Inter- and Intraobserver Study. AJNR Am J Neuroradiol 2021; 42:501-507. [PMID: 33509923 DOI: 10.3174/ajnr.a7021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/24/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Conventional angiography is the benchmark examination to diagnose cerebral vasospasm, but there is limited evidence regarding its reliability. Our goals were the following: 1) to systematically review the literature on the reliability of the diagnosis of cerebral vasospasm using conventional angiography, and 2) to perform an agreement study among clinicians who perform endovascular treatment. MATERIALS AND METHODS Articles reporting a classification system on the degree of cerebral vasospasm on conventional angiography were systematically searched, and agreement studies were identified. We assembled a portfolio of 221 cases of patients with subarachnoid hemorrhage and asked 17 raters with different backgrounds (radiology, neurosurgery, or neurology) and experience (junior ≤10 and senior >10 years) to independently evaluate cerebral vasospasm in 7 vessel segments using a 3-point scale and to evaluate, for each case, whether findings would justify endovascular treatment. Nine raters took part in the intraobserver reliability study. RESULTS The systematic review showed a very heterogeneous literature, with 140 studies using 60 different nomenclatures and 21 different thresholds to define cerebral vasospasm, and 5 interobserver studies reporting a wide range of reliability (κ = 0.14-0.87). In our study, only senior raters reached substantial agreement (κ ≥ 0.6) on vasospasm of the supraclinoid ICA, M1, and basilar segments and only when assessments were dichotomized (presence or absence of ≥50% narrowing). Agreement on whether to proceed with endovascular management of vasospasm was only fair (κ ≤ 0.4). CONCLUSIONS Research on cerebral vasospasm would benefit from standardization of definitions and thresholds. Dichotomized decisions by experienced readers are required for the reliable angiographic diagnosis of cerebral vasospasm.
Collapse
Affiliation(s)
- T E Darsaut
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - C Derksen
- Stroke Program (C.D.), Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - B Farzin
- Research Center (B.F., G.G., J.R.)
| | - M B Keough
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - R Fahed
- Department of Medicine (R.F.), Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - W Boisseau
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - L Letourneau-Guillon
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - A-C Januel
- Service de Neuroradiologie (A.-C.J.), Hôpital Purpan, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - A Weill
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - D Roy
- Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| | - T N Nguyen
- Service of Interventional Neurology and Neuroradiology (T.N.N.), Boston Medical Center, Boston, Massachusetts
| | - S Finitsis
- Department of Radiology (S.F.), Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - J-C Gentric
- Department of Radiology (J.-C.G.), Division of Neuroradiology, Centre Hospitalier Universitaire Cavale Blanche, Brest, France
| | - D Volders
- Department of Radiology (D.V.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - A Carlson
- Department of Neurosurgery (A.C.), University of New Mexico, Albuquerque, New Mexico
| | - M M Chow
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - C O'Kelly
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - J L Rempel
- Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), University of Alberta hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
| | - R A Ashforth
- Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), University of Alberta hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Province du Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Province du Québec, Canada
| | - J M Findlay
- From the Department of Surgery (T.E.D., M.B.K., M.M.C., C.O., J.M.F.), Division of Neurosurgery
| | - G Gevry
- Research Center (B.F., G.G., J.R.)
| | - J Raymond
- Research Center (B.F., G.G., J.R.) .,Department of Radiology (W.B., L.L.-G., A.W., D.R., J.R.), Centre Hospitalier de l'Université de Montréal, Montreal, Province du Québec, Canada
| |
Collapse
|