Endovascular embolization vs surgical clipping in treatment of cerebral aneurysms: morbidity and mortality with short-term outcome

doi:10.1016/j.surneu.2005.12.031

Surgical Neurology

Volume 66, Issue 3, September 2006, Pages 277-284

https://doi.org/10.1016/j.surneu.2005.12.031 Get rights and content

Abstract

Background

Endovascular embolization of cerebral aneurysms has evolved rapidly worldwide within the last years, and has gained more popularity at the expense of surgical clipping; however, both regimens have inherent risks. This study was undertaken to asses the cerebral complications associated with both modalities of cerebral aneurysm treatment.

Methods

We retrospectively reviewed the charts, operative and embolization reports, and imaging of patients who underwent surgical clipping or embolization for cerebral aneurysms at our institution between October 2001 and October 2004. Patients were divided into 2 groups: group A, patients who had confirmed subarachnoid hemorrhage; group B, patients with unruptured cerebral aneurysms. Patients belonging to group A were evaluated according to the Hunt and Hess scale with their computed tomography scan evaluated according to Fisher scale. Short-term outcome was measured with Glasgow Outcome Scale for both groups.

Results

One hundred thirty-three patients with 168 aneurysms were treated; 95 (71.4%) were women and 38 (28.6%) men; mean age was 60.28 years. Hypertension (29.6%) was the most commonly encountered risk factor; average size of aneurysms treated was 7.21 mm; 53 patients belonged to group A. Seven patients were Hunt and Hess grade I, 23 grade II, 11 grade III, 7 grade IV, and 5 grade V. Eighty patients belonged to group B; for both groups, the periprocedural technical complication rate associated with coiling was 8.4% vs 19.35% with clipping. Follow-up angiographic results were better with clipping, as total aneurysm occlusion was 81.4% vs 57.5% with coiling. In group A, the incidence of angiographic vasospasm was 17.4% vs 45.4% with coiling vs clipping, whereas the incidence of shunt-dependant hydrocephalus was comparable with embolization and clipping. In group A, excellent outcome was achieved in 62% vs 44% (endovascular vs surgical) of subgroups, whereas in group B, it was 93% vs 81%, respectively.

Conclusion

With rapidly evolving technology of endovascular embolization, accumulated experience, and good selection of patients with optimum angioanatomical criteria and endovascular accessibility, our results of morbidity and mortality associated with both modalities of cerebral aneurysm treatment with short-term outcome show that endovascular embolization of cerebral aneurysms is a safe alternative to surgical clipping in the treatment of both ruptured and unruptured cerebral aneurysms; however, long-term outcome needs to be evaluated.

Introduction

The goal of aneurysm treatment is complete, immediate, permanent, and safe occlusion of the dome and preservation of the parent artery [28]. Although surgical clipping is considered the standard for aneurysm treatment, approximately 2.3% to 8.2% [19], [36] and as high as 42% [17], [18] of aneurysms treated using surgical clipping demonstrated residual aneurysms (ear dog or broad based) together with estimated rates of 3% to 10% surgical complication [1], [19], [20], [21]. The rapid evolution of imaging, preoperative care, neuroanesthesia, endovascular embolization, and the few advances in aneurysm clip technology or application techniques [35], [37] changed the indication of endovascular coiling of cerebral aneurysms from failed surgical clipping, poor medical condition, refusal to undergo surgery, and old age [3], [4], [22], [27] to be an accepted alternative to surgical clip placement in dealing with ruptured and unruptured cerebral aneurysms [10], [13], [14], [34]. However, endovascular embolization is not without complication; the main disadvantages of this technique compared with surgery are aneurysm recurrence and inherent risks of morbidity and mortality despite increasing clinical experience and technological improvement [2], [22], [29]. The aim of this study was to retrospectively review our experience with both modalities of cerebral aneurysm treatment with special interest to their cerebral complications.

Section snippets

Patients and methods

Between October 2001 and October 2004, a total of 164 patients with cerebral aneurysms were treated at Kokura Memorial Hospital; 31 patients with incomplete data, who were lost to follow-up, and with multiple cerebral aneurysms when both modalities were applied for the same patient were excluded; the remaining 133 patients harboring 168 aneurysms were included in this study (Table 1). We retrospectively reviewed the medical reports, radiographic studies, endovascular and surgical reports,

Periprocedural complications with coiling

Six (8.4%) complications were noted in 28 patients in group A and in 43 patients in group B who were treated with embolization (Table 2); 4 were with initial embolization of the ruptured group and 2 with coiling of the unruptured group. The aforementioned complications in the ruptured group were aneurysmal perforation; 3 occurred at the time of embolization, with immediate delivery of additional coils, reversal of heparin, and compression of ipsilateral carotid for anterior circulation

Discussion

Endovascular treatment of cerebral aneurysms was revolutionized with the introduction of electrolytically detachable coils. The work of Guglielmi et al [9] was soon followed by numerous publications that investigated this new technique; several researches by different groups were undertaken to document and analyze the complications associated with this endeavor and compare it with the previous standard surgical clipping with variable results in patients with ruptured and unruptured aneurysms.

Conclusion

Our retrospective study indicates that the periprocedural technical complications associated with endovascular embolization was lower than surgery-related complications associated with microsurgical clip placement for both ruptured and unruptured cerebral aneurysms. The incidence of post-SAH vasospasm was lower in patients treated with coiling. As compared with patients treated with clipping, shunt-dependant hydrocephalus was comparable in both modalities of aneurysm treatment. The follow-up

References (39)

R.J. Andrews et al.
A review of brain retraction and recommendations for minimizing intraoperative brain injury
Neurosurgery
(1993)
E.H. Brilsra et al.
A treatment of intracranial aneurysms by embolisation with coils: a systemic review
Stroke
(1999)
A.E. Casasco et al.
Selective endovascular treatment of 71 intracranial aneurysms with platinum coils
J Neurosurg
(1993)
A.R. Dehdashti et al.
Shunt-dependant hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality
J Neurosurg
(2004)
Z. Dorai et al.
Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage
Neurosurgery
(2003)
C.M. Fisher et al.
Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning
Neurosurgery
(1980)
L.M. Flet et al.
Aneurysmal subarachnoid hemorrhage: management strategies and clinical outcomes in a regional neuroscience center
AJNR Am J Neuroradiol
(2003)
A. Gruber et al.
Evaluation of cerebral vasospasm after early surgical and endovascular treatment of ruptured intracranial aneurysms
Neurosurgery
(1998)
G. Guglielmi et al.
Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience
J Neurosurg
(1991)
H. Henkes et al.
Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic and clinical results
Neurosurgery
(2004)

B.L. Hoh et al.

Effect of clipping, craniotomy, or intravascular coiling on cerebral vasospasm and patient outcome after aneurysmal subarachnoid hemorrhage

Neurosurgery

(2004)

W.E. Hunt et al.

Surgical risk as related to time of intervention in the repair of intracranial aneurysms

J Neurosurg

(1968)

International Study of Unruptured Intracranial Aneurysms Investigators

Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment

Lancet

(2003)

International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2134 patients with ruptured intracranial aneurysms :a randomized clinical trial

Lancet

(2002)

B. Jennet et al.

Assessment of outcome after sever brain damage

Lancet

(1975)

S.C. Johnston et al.

Surgical and endovascular treatment of unruptured cerebral aneurysms at university hospital

Neurology

(1999)

H.S. Kang et al.

Postoperative 3D angiography in intracranial aneurysms

AJNR Am J Neuroradiol

(2004)

N.F. Kassell et al.

The international cooperative study on the timing of aneurysm surgery. Part I: overall management results

J Neurosurg

(1990)

N.F. Kassell et al.

The international cooperative study on the timing of aneurysm surgery. Part II: surgical results

J Neurosurg

(1990)

Cited by (68)

Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample
2020, Journal of Stroke and Cerebrovascular Diseases
In an unprecedented era of soaring healthcare costs, payers and providers alike have started to place increased importance on measuring the quality of surgical procedures as a surrogate for operative success. One metric used is the length of hospital stay (LOS) during index admission. For the treatment of unruptured cerebral aneurysms, the determinants of extended length of stay are relatively unknown. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS following treatment for unruptured cerebral aneurysms.
The National Inpatient Sample years 2010 – 2014 was queried. Adults (≥18 years) with unruptured aneurysms undergoing either clipping or coiling were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended LOS was defined as greater than 75^th percentile for the entire cohort (>5 days). Weighted patient demographics, comorbidities, complications, LOS, disposition and total cost were recorded. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree which patient comorbidities or postoperative complications correlated with extended LOS.
A total of 46,880 patients were identified for which 9,774 (20.8%) patients had extended LOS (Normal LOS: 37,106; Extended LOS: 9,774). Patients in the extended LOS cohort presented with a greater number of comorbidities compared to the normal LOS cohort. A greater proportion of the normal LOS cohort was coiled (Normal LOS: 63.0% vs. Extended LOS: 33.5%, P<0.001), while more patients in the extended LOS cohort were clipped (Normal LOS: 37.0% vs. Extended LOS: 66.5%, P<0.001). The overall complication rate was higher in the extended LOS cohort (Normal LOS: 7.3% vs. Extended LOS: 43.8%, P<0.001). On average, the extended LOS cohort incurred a total cost nearly twice as large (Normal LOS: $26,050 ± 13,430 vs. Extended LOS: $52,195 ± 37,252, P<0.001) and had more patients encounter non-routine discharges (Normal LOS: 8.5% vs. Extended LOS: 52.5%, P<0.001) compared to the normal LOS cohort. On weighted multivariate logistic regression, multiple patient-specific factors were associated with extended LOS. These included demographics, preadmission comorbidities, choice of procedure, and inpatient complications. The odds ratio for extended LOS was 5.14 (95% CI, 4.30 – 6.14) for patients with 1 complication and 19.58 (95% CI, 15.75 – 24.34) for patients with > 1 complication.
Our study demonstrates that extended LOS after treatment of unruptured aneurysms is influenced by a number of patient-level factors including demographics, preadmission comorbidities, type of aneurysm treatment (open surgical versus endovascular), and, importantly, inpatient complications. A better understanding of these independent predictors of prolonged length of hospital stay may help to improve patient outcomes and decrease overall healthcare costs.
Neurosurgical Clipping versus Endovascular Coiling for Patients with Intracranial Aneurysms: A Systematic Review and Meta-Analysis
2020, World Neurosurgery
We compared the efficacy and safety of neurosurgical clipping with those of endovascular coiling for patients with intracranial aneurysm (IA) stratified by country, publication year, study design, sample size, mean age, percentage of male patients, percentage of aneurysms located in the anterior circulation, and follow-up duration.
We identified 64 studies (7 randomized controlled trials, 21 prospective cohort studies, and 36 retrospective studies) of clipping versus coiling for IA from PubMed, EmBase, and the Cochrane Library up to September 2019.
No significant differences were found in the incidence of poor outcomes observed between clipping and coiling for patients with ruptured IAs. In contrast, the incidence of a poor outcome was significantly increased for unruptured IAs treated by clipping. Clipping was associated with a lower risk of mortality for ruptured IAs, although no significant differences were found between clipping and coiling for unruptured IAs. Clipping was associated with a lower risk of rebleeding for ruptured IAs and an increased risk of bleeding for unruptured IAs. When only randomized controlled trials were included in the analysis, patients with ruptured IAs treated by clipping had an increased incidence of poor outcomes compared with those treated by coiling. Clipping reduced the risk of hydrocephalus and incomplete occlusion and increased the rate of complete occlusion for ruptured IAs. No significant differences in the risk of ischemic infarct and vasospasm were found between clipping and coiling.
Surgical clipping might be superior to endovascular coiling for ruptured IAs. However, clipping was associated with a greater incidence of poor outcomes and bleeding compared with coiling for unruptured IAs.
Orbital Compartment Syndrome Secondary to Direct Carotid Cavernous Fistula After Carotid Cavernous Aneurysm Rupture: Case Report and Review of Literature
2020, World Neurosurgery
Carotid cavernous aneurysm (CCA) rupture is rare. However, it can result in various complications such as carotid cavernous fistula (CCF), epistaxis, spontaneous thrombosis, and subarachnoid hemorrhage.
We report a 65-year-old woman with a history of uncontrolled diabetes who was referred with complaints of acute headache, diplopia, proptosis, and chemosis. Ophthalmic examination revealed elevated intraocular pressure in the right eye, optic disk edema, and retinal venous congestion. Canthotomy was performed based on a diagnosis of orbital compartment syndrome (OCS). Further imaging revealed a dilated superior ophthalmic vein and cavernous sinus, as well as swelling of the extraocular muscles in the right eye. Digital subtraction angiography revealed the fistulous connection between the cavernous part of the internal carotid and cavernous sinus (direct CCF) due to the large ruptured CCA, resulting in retrograde flow through the superior and inferior ophthalmic veins. Successful endovascular coiling of the aneurysm resulted in complete occlusion of the fistula. Postintervention ophthalmic examination demonstrated progressive improvement of ophthalmic signs and symptoms; however, the patient's right eye remained sightless.
In patients with clinical manifestation of OCS with no history of any predisposing risk factors, diagnosis of ruptured cavernous sinus aneurysm and resulting direct CCF should be considered. In such cases, emergent imaging along with early endovascular intervention can resolve OCS and prevent permanent ocular injury and vision loss.
Clipping Versus Coiling in the Management of Unruptured Aneurysms with Multiple Risk Factors
2019, World Neurosurgery
We investigated the outcomes of patients with an unruptured intracranial aneurysm (UIA) and >2 risk factors concerning complications, obliteration rate, and other factors after surgical or endovascular treatment.
Coiling and clipping were compared in patients with UIAs treated in West China Hospital from January 2015 to May 2017. Patient survival, dependency, retreatment, complications, and other clinical outcome indexes were compared between the 2 groups.
A total of 82 patients (92 aneurysms) had undergone treatment for UIAs with multiple risk factors. Of these 82 patients, 45 (54.9%) had undergone clipping and 37 (45.1%) had undergone coiling. No deaths were related to either treatment. Morbidity (modified Rankin scale score >2) at 1 year had developed in 1 of 45 and 1 of 37 patients in the clipping and coiling groups, without a statistically significant difference. Hospitalization >5 days (30 of 45 vs. 12 of 37; P < 0.05) was less frequent after coiling. The number of aneurysms with complete occlusion (48 of 51 vs. 33 of 41; P < 0.05) was greater in the surgical group. No differences in peritreatment complications were found in the surgical and endovascular groups (8 of 45 vs. 6 of 37; P > 0.05).
In our study, clipping and coiling showed advantages for the treatment of UIAs with multiple risk factors. Surgical clipping of UIAs is achievable with a low rate of unfavorable outcomes and a high rate of complete obliteration for patients with multiple risk factors. However, endovascular treatment was also successful, with a shorter length of stay and low procedure-related morbidity. Additional randomized evidence are required to support the superior efficacy of clipping.
Comparing the Risk of Shunt-Dependent Hydrocephalus in Patients with Ruptured Intracranial Aneurysms Treated by Endovascular Coiling or Surgical Clipping: An Updated Meta-Analysis
2019, World Neurosurgery
Citation Excerpt :
This difference did not reach statistical significance (P = 0.53). After that, we solely chose 7 retrospective studies4,5,9,17,32,18,19 (n = 12,378) reporting shunt-dependent hydrocephalus found that clipping was associated with a lower shunt-dependent hydrocephalus rate (shunt-dependent hydrocephalus rate with clipping vs. coiling: 10.0% vs. 11.1%; RR, 0.88; 95% CI, 0.79–0.98). However, we should carefully accept the results of the meta-analysis from the 7 retrospective studies because the characteristics of the patients differed greatly within each study.
This meta-analysis aimed to evaluate the risk of shunt-dependent hydrocephalus among patients with ruptured intracranial aneurysms treated with either coil placement or clipping.
A systematic literature search of Embase, PubMed, Web of Science, and the Cochrane Library was performed to confirm relevant studies. The scientific literature was screened in accordance with the predetermined inclusion and exclusion criteria. After quality assessment and data extraction from the eligible studies, a meta-analysis was conducted using the STATA 12.0 software (Stata corporation, College Station, Texas, USA).
Thirteen studies met all inclusion criteria and were included in the analysis. In total, these studies included 13,751 patients. Of the patients, 8444 of them underwent neurosurgical clipping, and 5307 underwent endovascular coiling. The overall result of a pooled estimate revealed there was no statistically significant risk of shunt dependency difference between the clipping and coiling groups (11.4% vs. 12.0%, respectively; relative risk [RR], 0.92; 95% confidence interval [CI], 0.84–1.01). Six prospective studies (n = 1373) reported shunt-dependent hydrocephalus revealed no significant difference between clipping and coiling (23.3% vs. 20.1%, respectively; RR, 1.12; 95% CI, 0.91–1.38). Seven retrospective studies (n = 12,378) reported shunt-dependent hydrocephalus found statistical significance between the surgical and endovascular treatment groups (10.0% vs. 11.1%, respectively; RR, 0.88; 95% CI, 0.79–0.98).
Microsurgical clipping and endovascular coiling of ruptured cerebral aneurysms are associated with similar incidences of ventricular shunt placement for hydrocephalus. The risk of shunt-dependent hydrocephalus is not higher after coiling than after clipping of ruptured intracranial aneurysms.
No Disparity in Outcomes Between Surgical Clipping and Endovascular Coiling After Aneurysmal Subarachnoid Hemorrhage
2018, World Neurosurgery
Aneurysmal subarachnoid hemorrhage (SAH) can be treated with either endovascular coiling or surgical clipping. The International Subarachnoid Aneurysm Trial (ISAT) found that endovascular coiling provided lower mortality rates at 1-year follow-up, starting a trend toward the endovascular treatment approach for SAH. Subsequently, specific procedural indications have driven an approach to SAH management involving a patient-specific procedural choice. The present study evaluates whether specific indications for these procedures have eliminated the differences in risk-adjusted mortality and in-hospital complications from SAH in a large nationally representative set of hospitalizations from 2013 to 2014.
All cases of nontraumatic subarachnoid hemorrhage were queried from the National Inpatient Sample using codes from the International Classification of Diseases, 9th edition. These patients were assigned to cohorts based on whether they were treated by surgical clipping or by endovascular coiling. Subsequent univariate and multivariate analyses were used to characterize and compare demographics, in-hospital complications, and total charges between the 2 groups.
In 2013 to 2014, 6555 patients hospitalized for SAH underwent surgical clipping and 15,350 underwent endovascular coiling. The patients undergoing coiling were older (55.3 vs. 54.1, P = 0.02) and had lower severity scores (3.24 vs. 3.44, P < 0.0001); however, they had higher average risk of mortality scores (2.96 vs. 2.44, P < 0.0001) and longer lengths of stay (19.0 vs. 17.8 days, P = 0.009) than did those undergoing surgical clipping. Multivariate logistic regression analysis comparing clipping to coiling showed no differences in rates of complication (odds ratio [OR]: 0.87; 95% confidence interval [CI]: 0.67–1.13), death (OR: 0.78; 95% CI: 0.57–1.05), or total charges (−$3282, 95% CI: −$8376–$14,941) between both cohorts.
Concerns about overzealous use of endovascular coiling in treating SAH after the ISAT stemmed from a lag in condition-specific indications. The allure of endovascular coiling stems from its noninvasiveness and initial results; however, in the years after ISAT, evaluation of SAH conditions led to more patient-specific indications for SAH. The results presented here suggest that more rigorous procedural selection has allowed for an optimization of outcomes for the 2 procedures.

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AneurysmEndovascular embolization vs surgical clipping in treatment of cerebral aneurysms: morbidity and mortality with short-term outcome

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Periprocedural complications with coiling

Discussion

Conclusion

A review of brain retraction and recommendations for minimizing intraoperative brain injury

Neurosurgery

A treatment of intracranial aneurysms by embolisation with coils: a systemic review

Stroke

Selective endovascular treatment of 71 intracranial aneurysms with platinum coils

J Neurosurg

Shunt-dependant hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality

J Neurosurg

Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage

Neurosurgery

Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning

Neurosurgery

Aneurysmal subarachnoid hemorrhage: management strategies and clinical outcomes in a regional neuroscience center

AJNR Am J Neuroradiol

Evaluation of cerebral vasospasm after early surgical and endovascular treatment of ruptured intracranial aneurysms

Neurosurgery

Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience

J Neurosurg

Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic and clinical results

Neurosurgery

Effect of clipping, craniotomy, or intravascular coiling on cerebral vasospasm and patient outcome after aneurysmal subarachnoid hemorrhage

Neurosurgery

Surgical risk as related to time of intervention in the repair of intracranial aneurysms

J Neurosurg

Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment

Lancet

International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2134 patients with ruptured intracranial aneurysms :a randomized clinical trial

Lancet

Assessment of outcome after sever brain damage

Lancet

Surgical and endovascular treatment of unruptured cerebral aneurysms at university hospital

Neurology

Postoperative 3D angiography in intracranial aneurysms

AJNR Am J Neuroradiol

The international cooperative study on the timing of aneurysm surgery. Part I: overall management results

J Neurosurg

The international cooperative study on the timing of aneurysm surgery. Part II: surgical results

J Neurosurg

Aneurysm
Endovascular embolization vs surgical clipping in treatment of cerebral aneurysms: morbidity and mortality with short-term outcome