Clipping Versus Coiling for Ruptured Intracranial Aneurysms A Systematic Review and Meta-Analysis

From the Department of Neurology and Department of Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
Stroke (Impact Factor: 5.72). 12/2012; 44(1). DOI: 10.1161/STROKEAHA.112.663559
Source: PubMed


Background and purpose:
Endovascular treatment has increasingly been used for aneurismal subarachnoid aneurismal hemorrhage. The aim of this analysis is to assess the current evidence regarding safety and efficiency of clipping compared with coiling.

We conducted a meta-analysis of studies that compared clipping with coiling between January 1999 and July 2012. Comparison of binary outcomes between treatment groups was described using odds ratios (OR; clip versus coil).

Four randomized controlled trials and 23 observational studies were included. Randomized controlled trials showed that coiling reduced the 1-year unfavorable outcome rate (OR, 1.48; 95% confidence interval [CI], 1.24-1.76). However, there was no statistical deference in nonrandomized controlled trials (OR, 1.11; 95% CI, 0.96-1.28). Subgroup analysis revealed coiling yielded better outcomes for patients with good preoperative grade (OR, 1.51; 95% CI, 1.24-1.84) than for poor preoperative patients (OR, 0.88; 95% CI 0.56-1.38). Additionally, the incidence of rebleeding is higher after coiling (OR, 0.43; 95% CI, 0.28-0.66), corresponding to a better complete occlusion rate of clipping (OR, 2.43; 95% CI, 1.88-3.13). The 1-year mortality showed no significant difference (OR, 1.07; 95% CI, 0.88-1.30). Vasospasm was more common after clipping (OR, 1.43; 95% CI, 1.07-1.91), whereas the ischemic infarct (OR, 0.74; 95% CI, 0.52-1.06), shunt-dependent hydrocephalus (OR, 0.84; 95% CI, 0.66-1.07), and procedural complication rates (OR, 1.19; 95% CI, 0.67-2.11) did not differ significantly between techniques.

Coiling yields a better clinical outcome, the benefit being greater in those with a good preoperative grade than those with a poor preoperative grade. However, coiling leads to a greater risk of rebleeding. Well-designed randomized trials with special considerations to the aspect are needed.

Download full-text


Available from: Xiaoming Rong, Mar 02, 2015
  • Source
    • "In 5 to 10% of cases, endovascular coiling is not possible due to morphological characteristics or location of the aneurysm. However, endovascular coiling is minimally invasive and therefore, it is preferred over traditional neurosurgical clipping [20,21]. Hypothermia has been shown to reduce edema formation and intracranial pressure after SAH and could be an important means to control fever in SAH. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Subarachnoid hemorrhage (SAH) represents a considerable health problem. To date, limited therapeutic options are available. In order to develop effective therapeutic strategies for SAH, the mechanisms involved in SAH brain damage should be fully explored. Here we review the mechanisms of SAH brain damage induced by the experimental endovascular puncture model. We have included a description of similarities and distinctions between experimental SAH in animals and human SAH pathology. Moreover, several novel treatment options to diminish SAH brain damage are discussed. SAH is accompanied by cerebral inflammation as demonstrated by an influx of inflammatory cells into the cerebral parenchyma, upregulation of inflammatory transcriptional pathways and increased expression of cytokines and chemokines. Additionally, various cell death pathways including cerebral apoptosis, necrosis, necroptosis and autophagy are involved in neuronal damage caused by SAH. Treatment strategies aiming at inhibition of inflammatory or cell death pathways demonstrate the importance of these mechanisms for survival after experimental SAH. Moreover, neuroregenerative therapies using stem cells are discussed as a possible strategy to repair the brain after SAH since this therapy may extend the window of treatment considerably. We propose the endovascular puncture model as a suitable animal model which resembles the human pathology of SAH and which could be applied to investigate novel therapeutic therapies to combat this debilitating insult.
    Journal of Neuroinflammation 01/2014; 11(1):2. DOI:10.1186/1742-2094-11-2 · 5.41 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Spontaneous non-traumatic subarachnoid hemorrhage (SAH), caused by the intracranial aneurysm rupture, is a severe cerebrovascular emergency. Cerebral and extracerebral complications are frequently associated to SAH and increase significantly the morbidity and mortality. SAH is a severe medical condition in which outcome can be considerably influenced by an early aggressive expert care. Guidelines have been recently published and offer a framework for treatment of SAH patients. The intensivists’ role in the management of SAH victims is crucial and encompasses prompt diagnosis, identification, and treatment of intracranial (as hydrocephalus, intracranial hypertension, metabolic and electric disturbances, vasospasm and delayed cerebral ischemia) along with extracranial complications (mainly cardiovascular, respiratory, endocrine…). Résumé L’hémorragie sous-arachnoïdienne spontanée (SAH), causée par la rupture d’anévrisme intracrânien, est une vraie urgence cérébrovasculaire. Des complications cérébrales et extracérébrales sont fréquemment associées au SAH, amenant à une augmentation significative de la morbimortalité. Le SAH est une pathologie grave, et la survie des patients qui en sont victimes peut être considérablement améliorée grâce à une prise en charge agressive précoce et une expertise spécialisée multidisciplinaire. Des recommandations ont été récemment publiées offrant une perspective et un cadre précis pour les patients atteints de SAH. Le rôle des réanimateurs dans la prise en charge des patients atteints de SAH est crucial et englobe un diagnostic rapide, l’identification et le traitement des complications intracrâniennes (comme l’hydrocéphalie, l’hypertension intracrânienne, les troubles métaboliques et électriques, le vasospasme et l’ischémie cérébrale retardée) et des complications extracrâniennes (principalement cardiovasculaires, respiratoires et endocriniennes).
    Réanimation 01/2013; 23(S2):425-432. DOI:10.1007/s13546-013-0810-8
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Considerable advances in our understanding of the natural history and treatment of cerebrovascular disease were made in 2012. The landmark Unruptured Cerebral Aneurysm Study in Japan was published, illustrating a significantly greater rupture risk than previously reported for small anterior and posterior communicating artery aneurysms, those with daughter domes, and giant aneurysms. Results from the Cerecyte (DePuy Synthes, West Chester, PN, USA) coil trial did not demonstrate a statistically significant positive impact of these bioactive coils on angiographic occlusion rates or outcome. The Clazosentan to Overcome Neurological Ischemia and Infarct Occurring after Subarachnoid Hemorrhage study was also published and unfortunately did not demonstrate an overall favorable long-term functional outcome rate for patients with aneurysmal subarachnoid hemorrhage receiving clazosentan. Studies furthering our understanding of the natural history and treatment of vascular malformations were also published, including large prospective natural history studies of cavernous malformations from the Mayo Clinic and the Scottish Audit of Intracranial Vascular Malformations database. Although pregnancy was found to be a significant risk factor for arteriovenous malformation hemorrhage, several studies did not demonstrate pregnancy as a significant risk factor for cavernous malformation hemorrhage. Finally, prospective randomized control trials illustrated significantly improved angiographic and clinical outcome results for both the Solitaire (ev3 Endovascular, Plymouth, MN, USA; SWIFT trial) and Trevo (Concentric Medical, Mountainview, CA, USA; TREVO 2 trial) stent retrievers as compared to the Merci (Concentric Medical) clot retriever.
    Journal of Clinical Neuroscience 04/2013; 20(6). DOI:10.1016/j.jocn.2013.03.011 · 1.38 Impact Factor
Show more