Tips

from Other Journals

Endovascular Coiling Has Better Outcomes than Surgery



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2003 Feb 15;67(4):815-816.

Subarachnoid hemorrhage from a ruptured intracranial aneurysm is a catastrophic event usually treated by craniotomy with clipping of the aneurysm. The surgery carries significant risks, and many surviving patients have neurologic deficits. Endovascular coiling was developed as a safer alternative to surgery. This newer procedure introduces platinum coils into the aneurysm to prompt occlusion. The International Subarachnoid Aneurysm Trial Collaborative Group conducted a large clinical trial to compare endovascular coiling with traditional craniotomy and clipping.

The trial randomized more than 2,000 patients who had a recent definite subarachnoid hemorrhage caused by an identified intracranial aneurysm and were suitable for either form of treatment. The principal outcome assessed was performance on a modified Rankin scale at two and 12 months. Data were also collected about subsequent episodes of bleeding, quality of life, and measures of health care costs.

The 1,073 patients randomized to endovascular treatment and the 1,070 allocated to neurosurgery were comparable, and almost all of the patients received their allocated treatment as the first procedure. Surgery was performed on average 1.7 days after the acute episode, and endovascular coiling was performed after 1.1 days. In the endovascular group, 190 patients (23.7 percent) were dead or dependent one year after the procedure compared with 243 patients (30.6 percent) allocated to neurosurgical treatment. This difference was statistically significant and represents a relative risk reduction of 22.6 percent and an absolute risk reduction of 6.9 percent. A greater proportion of patients treated neurosurgically also reported significant impairment of lifestyle (see accompanying table). Close to one half of the patients in each group reported no symptoms or only minor symptoms one year after the procedure. Rebleeding occurred rarely and was reported only in the endovascular group (two per 1,276 patient-years).

The authors conclude that endovascular coiling improves the chance of survival and good outcomes compared with neurosurgical clipping of intracranial aneurysms, but it is associated with a slight risk of delayed re-bleeding. While they acknowledge that the patients selected for the trial are not representative of all cases of subarachnoid hemorrhage, they believe that endovascular treatment is more likely to result in disability-free survival than is neurosurgical clipping.

Outcome at One Year in 1,594 Patients (Primary Outcome)

Modified Rankin scale Endovascular treatment (%), n = 801 Neurosurgery (%), n = 793

0—No symptoms

207 (25.8)

152 (19.2)

1—Minor symptoms

217 (27.1)

220 (27.7)

2—Some restriction in lifestyle

187 (23.4)

178 (22.4)

(0 to 2 inclusive)

611 (76.3)

550 (69.4)

3—Significant restriction in lifestyle

80 (10.0)

106 (13.4)

4—Partly dependent

24 (3.0)

32 (4.0)

5—Fully dependent

21 (2.6)

25 (3.2)

6—Dead

65 (8.1)

80 (10.1)

(3 to 6 inclusive)

190 (23.7)

243 (30.6)


note:Data in italics are primary outcomes.

Adapted with permission from International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002;360:1271.

Outcome at One Year in 1,594 Patients (Primary Outcome)

View Table

Outcome at One Year in 1,594 Patients (Primary Outcome)

Modified Rankin scale Endovascular treatment (%), n = 801 Neurosurgery (%), n = 793

0—No symptoms

207 (25.8)

152 (19.2)

1—Minor symptoms

217 (27.1)

220 (27.7)

2—Some restriction in lifestyle

187 (23.4)

178 (22.4)

(0 to 2 inclusive)

611 (76.3)

550 (69.4)

3—Significant restriction in lifestyle

80 (10.0)

106 (13.4)

4—Partly dependent

24 (3.0)

32 (4.0)

5—Fully dependent

21 (2.6)

25 (3.2)

6—Dead

65 (8.1)

80 (10.1)

(3 to 6 inclusive)

190 (23.7)

243 (30.6)


note:Data in italics are primary outcomes.

Adapted with permission from International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002;360:1271.

International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet October 26, 2002;360:1267–74, and Nichols DA, et al. Coils or clips in subarachnoid haemorrhage?. [Commentary] Lancet. October 26, 2002;360:1262–3.

editor's note: Subarachnoid hemorrhage occurs in six to eight per 100,000 adults annually. Besides making the diagnosis and arranging the urgent transfer to neurosurgical care, the family physician's most important role is to support family members who are making crucial decisions about surgery. As cautioned in a commentary accompanying this article, all the patients selected for the study had bleeds in the anterior circulation. Nevertheless, the evidence points in favor of the endovascular technique. In real life, the outcomes are highly dependent on the skill of the operator and the standards of perioperative care. Most cases in this study were managed at European regional centers with high patient volumes and significant experience in managing intracranial bleeding. For many of us, the hardest decision is between prompt local treatment or transfer to centers of excellence that offer more experience but necessitate a delay in intervention.—A.D.W.

 

Copyright © 2003 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

Navigate this Article