Outcome After Clipping and Coiling for Aneurysmal Subarachnoid Hemorrhage in Clinical Practice in Europe, USA, and Australia

• Published in: Neurosurgery Vol. 84; no. 5; pp. 1019 - 1027
• Main Authors: Lindgren, Antti, Turner, Ellie Bragan, Sillekens, Tomas, Meretoja, Atte, Lee, Jin-Moo, Hemmen, Thomas M, Koivisto, Timo, Alberts, Mark, Lemmens, Robin, Jääskeläinen, Juha E, Vergouwen, Mervyn D I, Rinkel, Gabriel J E
• Format: Journal Article
• Language: English
• Published: United States Oxford University Press 01.05.2019; Copyright by the Congress of Neurological Surgeons; Wolters Kluwer Health, Inc
• Subjects: Adult; Aneurysm; Aneurysm, Ruptured - mortality; Aneurysm, Ruptured - surgery; Aneurysms; Australia; Belgium; Blood Vessel Prosthesis; Cerebral aneurysm; Clinical medicine; Clinical trials; Comparative analysis; Datasets; Endovascular Procedures - instrumentation; Endovascular Procedures - methods; Endovascular Procedures - mortality; Epidemiology; Europe; Fatalities; Female; Finland; Hemorrhage; Hospitals; Humans; Intracranial Aneurysm - mortality; Intracranial Aneurysm - surgery; Male; Medical research; Middle Aged; Netherlands; Neurosurgery; Neurosurgical Procedures - instrumentation; Neurosurgical Procedures - methods; Neurosurgical Procedures - mortality; Patient outcomes; Regression analysis; Research—Human—Clinical Studies; Stroke; Subarachnoid hemorrhage; Subarachnoid Hemorrhage - mortality; Subarachnoid Hemorrhage - surgery; Surgical Instruments; Treatment Outcome; United Kingdom; United States; Australia; United States; Europe; United Kingdom; Netherlands; Belgium; Finland; United States > US; Subarachnoid hemorrhage; Intracranial aneurysm; Endovascular; Aneurysm; Clipping; Outcomes research; Epidemiology
• ISSN: 0148-396X; 1524-4040; 1524-4040
• DOI: 10.1093/neuros/nyy223

Abstract BACKGROUND Within 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). OBJECTIVE To study the association of coiling and clipping with outcome after aSAH in daily clinical practice. METHODS In 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. RESULTS In 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). CONCLUSION In 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.