Could late rebleeding overturn the superiority of cranial aneurysm coil embolization over clip ligation seen in the International Subarachnoid Aneurysm Trial?

Abstract

OBJECT:

The present purpose is to define the sensitivity of the superiority of coil embolization observed in the International Subarachnoid Aneurysm Trial (ISAT) according to the rate of late rebleeding over a reasonable range, and to find the range of rebleeding rates for which it may be overturned. In the ISAT, coil embolization appears to be safer than clip ligation at 1 year, and clip occlusion has better long-term efficacy at preventing rebleeding. This leaves open the question of which is better in the longer term.

METHODS:

The authors calculate the life expectancy of patients following a subarachnoid hemorrhage (SAH) and compare the life expectancy of those who underwent coil embolization with those who underwent clip ligation in the ISAT cohort.

RESULTS:

The 1-year poor outcome rate following treatment climbs rapidly with advancing age. A consequence is that the absolute difference between the poor outcome rates after coil embolization and clip occlusion is lower in those < 50 years of age (3.3%) than it is for those > 50 years of age (10.1%). This difference may be enough to give clip application the advantage in the < 40-year-old group despite the small size of the difference in 1-year rebleeding rates thus far observed (0.152%).

CONCLUSIONS:

When treating ruptured cerebral aneurysms, the advantage of coil embolization over clip ligation cannot be assumed for patients < 40 years old. In this age range the difference in the safety of the 2 procedures is small, and the better long-term protection from SAH afforded by clip placement may give this treatment an advantage in life expectancy for patients < 40 years of age.

• Authors: Patrick Mitchell, Richard Kerr, A David Mendelow, Andy Molyneux
• Journal: Journal of neurosurgery (J Neurosurg) Vol. 108 Issue 3 Pg. 437-42 (Mar 2008) ISSN: 0022-3085 [Print] United States
• PMID: 18312088 (Publication Type: Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Topics

• Adult
• Age Factors
• Aged
• Aged, 80 and over
• Aneurysm, Ruptured (complications, mortality, therapy)
• Angioplasty
• Embolization, Therapeutic (adverse effects, instrumentation, methods)
• Female
• Follow-Up Studies
• Humans
• Intracranial Aneurysm (complications, mortality, therapy)
• Ligation
• Male
• Middle Aged
• Recurrence
• Subarachnoid Hemorrhage (etiology, mortality, therapy)
• Survival Rate
• Treatment Outcome