Endovascular coiling versus neurosurgical clipping for people with aneurysmal subarachnoid haemorrhage.
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SUBMITTER: Lindgren A
PROVIDER: S-EPMC6513627 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundThe comparative effectiveness of the two treatment options (surgical clipping and endovascular coiling) for ruptured cerebral aneurysms has not been studied in real-world practice in the USA. We investigated the association between the treatment method for ruptured cerebral aneurysms and outcomes.MethodsWe performed a retrospective cohort study of elderly patients who underwent treatment for ruptured cerebral aneurysms from 2007 to 2012 using a 100% sample of Medicare fee-for-service claims data. An instrumental variable analysis was used to control for unmeasured confounding and to create pseudo-randomization on the treatment method. In sensitivity analysis, controlling only for measured confounding, we used propensity score conditioning and inverse probability weighting with mixed effects to account for clustering at the Hospital Referral Region (HRR) level.ResultsDuring the study period 3210 patients underwent treatment for ruptured cerebral aneurysms and met the inclusion criteria. Of these, 1206 (37.6%) had surgical clipping and 2004 (62.4%) had endovascular coiling. Instrumental variable analysis demonstrated no difference between coiling and clipping in 1-year postoperative mortality (OR 1.04; 95% CI 0.70 to 1.54), likelihood of discharge to rehabilitation (OR 1.07; 95% CI 0.72 to 1.58), or 30-day readmission rate (OR 1.44; 95% CI 0.70 to 1.87). However, clipping was associated with 2.7 days longer length of stay (LOS) (95% CI 0.45 to 4.99). The same associations were present in propensity score adjusted and inverse probability weighted models.ConclusionsIn a cohort of Medicare patients, we did not demonstrate a difference in mortality, rate of discharge to rehabilitation, and readmissions between clipping and coiling of ruptured cerebral aneurysms. Clipping was associated with a slightly longer LOS.
| S-EPMC5033047 | biostudies-literature
Project description:BackgroundTo compare the effects of endovascular coiling and neurosurgical clipping in patients with unruptured intracranial aneurysm.MethodsSixteen electronic databases were searched for articles published between 1950 and July 2010 to compare clinical outcomes of clipping and coiling. Researchers reviewed all searched articles and extracted data independently. The quality of studies and evidence were evaluated using MINORS and GRADEprofiler, respectively. The odds ratio (OR) was calculated using the inverse variance meta-analysis method for each study outcome. To assess heterogeneity of ORs across cohorts, Cochran's Q statistic and I² were used.ResultsOf 4160 studies, 24 were identified (n = 31865). Clipping resulted in significantly higher disability using the Glasgow Outcome Scale (OR, 2.38; 95% CI, 1.33-4.26) and Modified Rankin Scale (OR, 2.83; 95% CI, 1.42-5.63) when compared with coiling. ORs for complications were also higher with clipping (ORs for neurological and cardiac complications were 1.94 with a 95% confidence interval [CI] of 1.09-3.47 and 2.51 with a 95% CI of 1.15-5.50). Clipping resulted in significantly greater disability in the short term (?6 m)(OR on the Glasgow Outcome Scale, 2.72; 95% CI, 1.16-6.34), but not in the long term (>6 m)(OR for Glasgow Outcome Scale, 2.12; 95% CI, 0.93-4.84).ConclusionsCoiling was a better procedure for treatment of unruptured intracranial aneurysm in terms of disability, complications, especially in the short term. Because of the limitations of the reviewed studies, further studies are required to support the present results.
| S-EPMC3519507 | biostudies-literature
Project description: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.
| S-EPMC8976818 | biostudies-literature
Project description:BackgroundPrevious analyses of the International Subarachnoid Aneurysm Trial (ISAT) cohort have reported on the risks of recurrent subarachnoid haemorrhage and death or dependency for a minimum of 5 years and up to a maximum of 14 years after treatment of a ruptured intracranial aneurysm with either neurosurgical clipping or endovascular coiling. At 1 year there was a 7% absolute and a 24% relative risk reduction of death and dependency in the coiling group compared with the clipping group, but the medium-term results showed the increased need for re-treatment of the target aneurysm in the patients given coiling. We report the long-term follow-up of patients in this UK cohort.MethodsIn ISAT, patients were randomly allocated to either neurosurgical clipping or endovascular coiling after a subarachnoid haemorrhage, assuming treatment equipoise, between Sept 12, 1994, and May 1, 2002. We followed up 1644 patients in 22 UK neurosurgical centres for death and clinical outcomes for 10·0-18·5 years. We assessed dependency as self-reported modified Rankin scale score obtained through yearly questionnaires. Data for recurrent aneurysms and rebleeding events were collected from questionnaires and from hospital and general practitioner records. The Office for National Statistics supplied data on deaths. This study is registered, number ISRCTN49866681.FindingsAt 10 years, 674 (83%) of 809 patients allocated endovascular coiling and 657 (79%) of 835 patients allocated neurosurgical clipping were alive (odds ratio [OR] 1·35, 95% CI 1·06-1·73). Of 1003 individuals who returned a questionnaire at 10 years, 435 (82%) patients treated with endovascular coiling and 370 (78%) patients treated with neurosurgical clipping were independent (modified Rankin scale score 0-2; OR 1·25; 95% CI 0·92-1·71). Patients in the endovascular treatment group were more likely to be alive and independent at 10 years than were patients in the neurosurgery group (OR 1·34, 95% CI 1·07-1·67). 33 patients had a recurrent subarachnoid haemorrhage more than 1 year after their initial haemorrhage (17 from the target aneurysm).InterpretationAlthough rates of increased dependency alone did not differ between groups, the probability of death or dependency was significantly greater in the neurosurgical group than in the endovascular group. Rebleeding was more likely after endovascular coiling than after neurosurgical clipping, but the risk was small and the probability of disability-free survival was significantly greater in the endovascular group than in the neurosurgical group at 10 years.FundingUK Medical Research Council.
| S-EPMC4356153 | biostudies-literature
Project description:Past studies revealed the prognosis differed between aneurysmal subarachnoid hemorrhage (aSAH) patients with surgical clipping and endovascular coiling. We retrospectively reviewed aSAH patients in our institution to investigate the effectiveness of grading scores between two groups. In the surgical clipping group (n?=?349), VASOGRADE had a favorable performance for predicting delayed cerebral ischemia (DCI) (area under curve (AUC)?>?0.750), and had better results than clinical (World Federation of Neurosurgical Societies (WFNS), Hunt & Hess (HH) and radiological scores (modified Fisher Scale (mFS), Subarachnoid Hemorrhage Early Brain Edema Score) (P?<?0.05). Clinical and combined scores (VASOGRADE, HAIR) had favorable performance for predicting poor outcome (AUC?>?0.750), and had better results than radiological scores (P?<?0.05). In the coiling group (n?=?320), none of the grading scores demonstrated favorable predictive accuracy for DCI (AUC?<?0.750). Only WFNS and VASOGRADE had AUC?>?0.700, with better performance than mFS (P?<?0.05). The clinical and combined scores showed favorable performance for predicting a poor outcome (AUC?>?0.750), and were better than the radiological scores (P?<?0.05). Radiological scores appeared inferior to the clinical and combined scores in clipping and coiling groups. VASOGRADE can be an effective grading score in patients with clipping or coiling for predicting DCI and poor outcome.
| S-EPMC7280262 | biostudies-literature
Project description:BackgroundMortality and morbidity of aneurysmal subarachnoid haemorrhage (aSAH) remain high, and prognosis is influenced by multiple non-modifiable factors such as aSAH severity. By analysing the chronology of aSAH management, we aim at identifying modifiable factors with emphasis on the occurrence of rebleeds in a setting with 24/7 surgical and endovascular availability of aneurysm repair and routine administration of tranexamic acid.MethodsRetrospective analysis of institutional quality registry data of aSAH cases admitted into neurosurgical care during the time period 01 January 2013-31 December 2017. We registered time and mode of aneurysm repair, haemorrhage patterns, course of treatment, mortality and functional outcome. Rebleeding was scored along the entire timeline from ictus to discharge from the primary stay.ResultsWe included 544 patients (368, 67.6% female), aged 58 ± 14 years (range 1-95 years). Aneurysm repair was performed in 486/544 (89.3%) patients at median 7.4 h after arrival and within 3, 6, 12 and 24 h in 26.8%, 44.7%, 73.0% and 96.1%, respectively. There were circadian variations in time to repair and in rebleeds. Rebleeding prior to aneurysm repair occurred in 9.7% and increased with aSAH severity and often in conjunction with patient relocations or interventions. Rebleeds occurred more often during surgical repair outside regular working hours, whereas rebleeds after repair (1.8%) were linked to endovascular repair.ConclusionsThe risk of rebleed is imminent throughout the entire timeline of aSAH management even with ultra-early aneurysm repair. Several modifiable factors can be linked to the occurrence of rebleeds and they should be identified and optimised within neurosurgical departments.
| S-EPMC7886745 | biostudies-literature
Project description:To estimate long-term medical resource consumption in patients with subarachnoid aneurysmal hemorrhage (SAH) receiving surgical clipping or endovascular coiling. From Taiwan's National Health Insurance Research Database, we enrolled patients with aneurysmal SAH who received clipping or coiling. After propensity score matching and adjustment for confounders, a generalized linear mixed model was used to determine significant differences in the accumulative hospital stay (days), intensive care unit (ICU) stay, and total medical cost for aneurysmal SAH, as well as possible subsequent surgical complications and recurrence. The matching process yielded a final cohort of 8102 patients (4051 and 4051 in endovascular coil embolization and surgical clipping, respectively) who were eligible for further analysis. The mean accumulative hospital stay significantly differed between coiling (31.2 days) and clipping (46.8 days; p < 0.0001). After the generalized linear model adjustment of gamma distribution with a log link, compared with the surgical clipping procedure, the adjusted odds ratios (aOR; 95% confidence interval [CI]) of the medical cost of accumulative hospital stay for the endovascular coil embolization procedure was 0.63 (0.60, 0.66; p < 0·0001). The mean accumulative ICU stay significantly differed between the coiling and clipping groups (9.4 vs. 14.9 days; p < 0.0001). The aORs (95% CI) of the medical cost of accumulative ICU stay in the endovascular coil embolization group was 0.61 (0.58, 0.64; p < 0.0001). The aOR (95% CI) of the total medical cost of index hospitalization in the endovascular coil embolization group was 0·85 (0.82, 0.87; p < 0.0001). Medical resource consumption in the coiling group was lower than that in the clipping group.
| S-EPMC8199713 | biostudies-literature
Project description:BackgroundWithin randomized clinical trials (RCTs), coiling of the ruptured aneurysm to prevent rebleeding results in better outcomes than clipping in patients with aneurysmal subarachnoid hemorrhage (aSAH).ObjectiveTo study the association of coiling and clipping with outcome after aSAH in daily clinical practice.MethodsIn this controlled, nonrandomized study, we compared outcomes after endovascular coiling and neurosurgical clipping of ruptured intracranial aneurysms in an administrative dataset of 7658 aSAH patients (22 tertiary care hospitals from Europe, USA, Australia; 2007-2013). Because the results contradicted those of the randomized trials, findings were further explored in a large clinical dataset from 2 European centers (2006-2016) of 1501 patients.ResultsIn the administrative dataset, the crude 14-d case-fatality rate was 6.4% (95% confidence interval [CI] 5.6%-7.2%) after clipping and 8.2% (95% CI 7.4%-9.1%) after coiling. After adjustment for age, sex, and comorbidity/severity, the odds ratio (OR) for 14-d case-fatality after coiling compared to clipping was 1.32 (95% CI 1.10-1.58). In the clinical dataset crude 14-d case fatality rate was 5.7% (95% CI 4.2%-7.8%) for clipping and 9.0% (95% CI 7.3%-11.2%) for coiling. In multivariable logistic regression analysis, the OR for 14-d case-fatality after coiling compared to clipping was 1.7 (95% CI 1.1-2.7), for 90-d case-fatality 1.28 (95% CI 0.91-1.82) and for 90-d poor functional outcome 0.78 (95% CI 0.6-1.01).ConclusionIn clinical practice, coiling after aSAH is associated with higher 14-d case-fatality than clipping and nonsuperior outcomes at 90 d. Both options need to be considered in aSAH patients. Further studies should address the reasons for the discrepancy between current data and those from the RCTs.
| S-EPMC8764701 | biostudies-literature
Project description:BackgroundThe 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).MethodsWe 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.ResultsWe 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).ConclusionCoiling 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.
| S-EPMC9310462 | biostudies-literature
Project description:Haptoglobin is the body's first line of defence against the toxicity of extracellular haemoglobin released following a subarachnoid haemorrhage (SAH). We investigated the haptoglobin response after SAH in cerebrospinal fluid (CSF) and serum. Paired CSF and serum samples from 19 controls and 92 SAH patients were assayed as follows: ultra-performance liquid chromatography for CSF haemoglobin and haptoglobin, immunoassay for serum haptoglobin and multiplexed CSF cytokines, and colorimetry for albumin. There was marked CSF haptoglobin deficiency: 99% of extracellular haemoglobin was unbound. The quotients for both CSF/serum albumin (qAlb) and haptoglobin (qHp) were used to compute the CSF haptoglobin index (qHp/qAlb). CSF from SAH patients had a significantly lower haptoglobin index compared to controls, especially in Haptoglobin-1 allele carriers. Serum haptoglobin levels increased after SAH and were correlated with CSF cytokine levels. Haptoglobin variables were not associated with long-term clinical outcomes post-SAH. We conclude that: (1) intrathecal haptoglobin consumption occurs after SAH, more so in haptoglobin-1 allele carriers; (2) serum haptoglobin is upregulated after SAH, in keeping with the liver acute phase response to central inflammation; (3) haptoglobin in the CSF is so low that any variation is too small for this to affect long-term outcomes, emphasising the potential for therapeutic haptoglobin supplementation.
| S-EPMC10707007 | biostudies-literature