Surgical and endovascular treatment of unruptured cerebral aneurysms at university hospitals

Objective: To compare complications of surgical clipping and coil embolization in the treatment of unruptured aneurysms. Background: Surgical clipping has been the preferred treatment for unruptured cerebral aneurysms but endovascular coil embolization is an increasingly employed alternative. No direct comparisons of the techniques are available to guide clinical decision making. Methods: We performed a cohort study of patients treated for unruptured cerebral aneurysms at 60 university hospitals from January 1994 through June 1997 using the University HealthSystem Consortium database. The database was validated by chart review from one of the participant universities. The main outcome measures were in-hospital mortality and adverse outcomes, defined as in-hospital deaths and discharges to nursing homes or rehabilitation hospitals. Results: The primary treatment modality was surgical in 2,357 cases and endovascular in 255 cases. Adverse outcomes were significantly more common in surgical cases (18.5%) compared to endovascular cases (10.6%) (p = 0.002), and the difference was not altered after adjusting for age, sex, race, transfer admissions, emergency room admissions, and year of treatment (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.4 to 3.3; p = 0.001). In-hospital mortality was also increased in surgical cases (2.3% versus 0.4%; p = 0.039), but the difference was not significant in the multivariable model (OR 6.3, 95% CI 0.9 to 46.1; p = 0.07). Length of stay and hospital charges were significantly greater for surgical cases (p < 0.0001 for each), and these differences were not affected by risk adjustment. Conclusion: Endovascular coil embolization resulted in fewer adverse outcomes than surgery for unruptured cerebral aneurysms treated at the university hospitals studied. Although these results should be seen as preliminary, the magnitude of difference and current predominance of surgery appear to justify a randomized trial.

[1]  A. Algra,et al.  Treatment of intracranial aneurysms by embolization with coils: a systematic review. , 1999, Stroke.

[2]  Didier Martin,et al.  Unruptured intracranial aneurysms--risk of rupture and risks of surgical intervention. , 1998, The New England journal of medicine.

[3]  M. Limburg,et al.  Mortality and Morbidity of Surgery for Unruptured Intracranial Aneurysms , 1998 .

[4]  Joon K. Song,et al.  Endovascular embolization of 150 basilar tip aneurysms with Guglielmi detachable coils: results of the Food and Drug Administration multicenter clinical trial. , 1998, Journal of neurosurgery.

[5]  S. Selvin,et al.  The burden, trends, and demographics of mortality from subarachnoid hemorrhage , 1998, Neurology.

[6]  R. Bryan,et al.  The treatment of acutely ruptured cerebral aneurysms: endovascular therapy versus surgery. , 1997, AJNR. American journal of neuroradiology.

[7]  F Viñuela,et al.  Intracranial aneurysms treated with the Guglielmi detachable coil: midterm clinical results in a consecutive series of 100 patients. , 1997, Journal of neurosurgery.

[8]  R. Higashida,et al.  Endovascular treatment of basilar tip aneurysms using electrolytically detachable coils. , 1996, Journal of neurosurgery.

[9]  S. Mayer,et al.  Relationship between the volume of craniotomies for cerebral aneurysm performed at New York state hospitals and in-hospital mortality. , 1996, Stroke.

[10]  G. Malik,et al.  Predicting outcome following surgical treatment of unruptured intracranial aneurysms: a proposed grading system. , 1996, Journal of neurosurgery.

[11]  C. Strother,et al.  Early treatment of ruptured aneurysms with Guglielmi detachable coils: effect on subsequent bleeding. , 1995, Neurosurgery.

[12]  T. Kirino,et al.  Quantification of operative benefit for unruptured cerebral aneurysms: a theoretical approach. , 1995, Journal of neurosurgery.

[13]  H. Glick,et al.  Elective surgery for asymptomatic, unruptured, intracranial aneurysms: a cost-effectiveness analysis. , 1995, Journal of neurosurgery.

[14]  R M Poses,et al.  Controlling for confounding by indication for treatment. Are administrative data equivalent to clinical data? , 1995, Medical care.

[15]  K. Worsley,et al.  Surgery of Unruptured, Asymptomatic Aneurysms: a Decision Analysis , 1995, Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques.

[16]  J. Berlin,et al.  Morbidity and mortality from elective surgery for asymptomatic, unruptured, intracranial aneurysms: a meta-analysis. , 1994, Journal of neurosurgery.

[17]  R. Higashida,et al.  The efficacy of endosaccular aneurysm occlusion in alleviating neurological deficits produced by mass effect. , 1994, Journal of neurosurgery.

[18]  R. A. Solomon,et al.  Surgical management of unruptured intracranial aneurysms. , 1994, Journal of neurosurgery.

[19]  J. Hodes,et al.  Selective endovascular treatment of 71 intracranial aneurysms with platinum coils. , 1993, Journal of neurosurgery.

[20]  F Viñuela,et al.  Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils. , 1992, Journal of neurosurgery.

[21]  V. Macellari,et al.  Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: Electrochemical basis, technique, and experimental results. , 1991, Journal of neurosurgery.

[22]  G. Duckwiler,et al.  Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience. , 1991, Journal of neurosurgery.

[23]  H. Adams,et al.  The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. , 1990, Journal of neurosurgery.

[24]  J D Habbema,et al.  Decision analysis of the management of incidental intracranial saccular aneurysms , 1986, Neurology.

[25]  F. P. Wirth,et al.  Surgical treatment of incidental intracranial aneurysms. , 1983, Clinical neurosurgery.

[26]  H. Winn,et al.  The natural history of aneurysms and arteriovenous malformations. , 1985, Journal of neurosurgery.

[27]  C. Drake,et al.  The late consequences of incomplete surgical treatment of cerebral aneurysms. , 1967, Journal of neurosurgery.