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Short term outcomes following clipping and coiling of ruptured intracranial aneurysms: does some of the benefit of coiling stem from less procedural impact on deranged physiology at presentation?
  1. Alex M Mortimer1,
  2. Celia Bradford2,
  3. Brendan Steinfort1,
  4. Ken Faulder1,
  5. Nazih Assaad3,
  6. Timothy Harrington1
  1. 1Department of Radiology, Royal North Shore Hospital, Sydney, New South Wales, Australia
  2. 2Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
  3. 3Department of Neurosurgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
  1. Correspondence to Dr A M Mortimer, Department of Radiology, Royal North Shore Hospital, Reserve Road, St Leonards, Sydney, NSW 2065, Australia; alex_mortimer{at}hotmail.com

Abstract

Background Endovascular coiling (EVC) has been shown to yield superior clinical outcomes to surgical clipping (SC) in the treatment of ruptured cerebral aneurysms. The reasons for these differences remain obscure. We aimed to assess outcomes of EVC and SC relative to baseline physiological derangement.

Methods This was an exploratory analysis of prospectively collected trial data. Physiological derangement was assessed using the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system. Other contributory variables such as age, World Federation of Neurosurgical Societies (WFNS) grade, and development of complications, including hydrocephalus and vasospasm, were included in the analysis. Clinical outcome was independently assessed at 90 days using the modified Rankin Scale (mRS). Hospital stay, ventilated days, and total norepinephrine dose were also used as secondary outcomes. Multivariate analysis was performed using binary logistic regression.

Results EVC was performed in 69 patients and SC in 66 patients. More profound physiological derangement (APACHE II score >15) was the strongest predictor of poor outcome in the overall cohort (OR 17.80, 95% CI 4.78 to 66.21, p<0.0001). For those with more deranged physiology (APACHE II score>15; 59 patients), WFNS grade ≥4 (OR 6.74, 1.43 to 31.75) and SC (OR 6.33, 1.27 to 31.38) were significant predictors of poor outcome (p<0.05). Favorable outcome (mRS 0–2) was seen in 11% of SC patients compared with 38% of EVC patients in this subgroup. SC patients had significantly increased total norepinephrine dose, ventilated days, and hospital stay (p<0.05).

Conclusions More profound physiological derangement at baseline is a strong predictor of eventual poor outcome, and outcomes for patients with more profound baseline physiological derangement may be improved if undergoing a coiling procedure.

  • Aneurysm
  • Coil
  • Complication
  • Intervention

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