Article

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: 6.02). 12/2012; 44(1). DOI: 10.1161/STROKEAHA.112.663559
Source: PubMed

ABSTRACT 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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

Full-text

Available from: Xiaoming Rong, Mar 02, 2015
0 Followers
 · 
85 Views
  • [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
  • [Show abstract] [Hide abstract]
    ABSTRACT: Migration of a coil during endovascular treatment of intracranial aneurysm occurs in 2-6% of cases. The consequences of coil migration vary significantly from minor flow alterations of the parent artery which are asymptomatic to thromboembolic occlusion of major intracranial vessels resulting in large territory infarcts. We performed a comprehensive literature review and identified 37 reported cases of migrated coil retrieval consisting of 10 case reports and six case series. Most of the aneurysms presented with rupture (65%) and were located in the anterior circulation (70%). The endovascular treatment approaches were coil embolization alone (57%), stent-assisted coiling (26%) and balloon remodeling (17%). Endovascular retrieval was performed with microwires, the Alligator Retrieval device, Merci devices, snares and stentrievers. There was a single report of microsurgical extraction following failed endovascular removal and three cases of coil fracture in which the coil fragments were secured to the vessel walls with stents.
    Journal of Neurointerventional Surgery 08/2013; 6(6). DOI:10.1136/neurintsurg-2013-010872 · 2.77 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Vasospasm is the leading source of neurological morbidity after aneurysmal subarachnoid hemorrhage (SAH). Our objective is to evaluate the impact of treatment modality on vasospasm, delayed cerebral infarction and clinical deterioration due to delayed cerebral ischemia (CD-DCI). The authors reviewed an institutional cohort comparing rates of vasospasm, delayed cerebral infarction, and CD-DCI between patients managed with only microsurgical clipping and those treated with only endovascular coiling within 72 hours of rupture. Age, sex, smoking status, Hunt-Hess grade and Fisher grade were adjusted for in a multivariate regression model. Two hundred and three patients were treated with clipping and fifty-two with coiling. There was no significant difference in patient age, sex, smoking status, aneurysm location, and presenting clinical (Hunt-Hess) and radiographic (Fisher) grade between these two groups. Sixty-percent of patients had moderate or severe vasospasm after clipping compared to 38% after coiling (Multivariate OR 2.32, 95% CI 1.21-4.47, p = 0.01). Clipping was associated with a greater number of territories with vasospasm (mean of 3.1 vs 2.3, p = 0.03 after multivariate analysis). Delayed radiographic cerebral infarction was more common in the clipping group (17% vs 6%, Multivariate OR 3.66, 95% CI 1.06-12.71, p = 0.04). For CD-DCI, a trend was seen as 16% of patients treated with clipping had CD-DCI compared to 6% of patients treated with coiling (Multivariate OR 3.11, 95% CI 0.89, 10.86, p = 0.07). We demonstrate significantly lower rates of vasospasm and delayed infarction after endovascular coiling of ruptured aneurysms.
    World Neurosurgery 08/2013; 82(6). DOI:10.1016/j.wneu.2013.08.017 · 2.42 Impact Factor
Show more