Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage
Abstract
Background
Patients who have had an aneurysmal subarachnoid haemorrhage (SAH) are at very high risk of rebleeding if the aneurysm is not treated. The standard treatment for several decades has been surgical clipping of the neck of the aneurysm. In recent years, an alternative, the introduction of detachable coils to occlude the aneurysm, has become more common.
Objectives
To compare the effects of endovascular coiling versus neurosurgical clipping in patients with aneurysmal subarachnoid haemorrhage.
Search methods
We searched the Cochrane Stroke Group Trials Register (last searched in February 2005). In addition we searched MEDLINE (1966 to January 2004) and EMBASE (1980 to January 2004), and contacted trialists.
Selection criteria
We included randomised trials in which endovascular coiling of aneurysms was compared with neurosurgical clipping in patients with SAH who have proven aneurysm.
Data collection and analysis
Two authors independently extracted the data and assessed trial quality. Trialists were contacted to obtain missing information.
Main results
We identified three randomised trials: two published and one unpublished. The trials included a total of 2272 patients (range per trial: 20 to 2143 patients). Most of the patients were in good clinical condition and had an aneurysm on the anterior circulation. After one year of follow up, the relative risk (RR) of poor outcome for coiling versus clipping was 0.76 (95% confidence interval (CI) 0.67 to 0.88). The absolute risk reduction was 7% (95% CI 4% to 11%). In the worst‐case scenario analysis for poor outcome overall, the relative risk for coiling versus clipping was 0.81 (95% CI 0.70 to 0.92) and the absolute risk reduction was 6% (95% CI 2% to 10%). For patients with anterior circulation aneurysm the relative risk of poor outcome was 0.78 (95% CI 0.68 to 0.90) and the absolute risk decrease was 7% (95% CI 3% to 10%). For those with a posterior circulation aneurysm the relative risk was 0.41 (95% CI 0.19 to 0.92) and the absolute decrease in risk 27% (95% CI 6% to 48%).
Authors' conclusions
The evidence comes mainly from one large trial. For patients in good clinical condition with ruptured aneurysms of either the anterior or posterior circulation we have firm evidence that, if the aneurysm is considered suitable for both surgical clipping and endovascular treatment, coiling is associated with a better outcome.
PICOs
Plain language summary
Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage
Endovascular coiling of ruptured aneurysms in the brain leads to a better outcome than surgical clipping. Bleeding on the surface of the brain is called a subarachnoid haemorrhage. The bleeding usually comes from the rupture of a weak spot in an artery carrying blood to the brain. This weak spot is like a small balloon, or blister, which is called an aneurysm. The outcome after subarachnoid haemorrhage is generally poor: half the patients die within one month; and of those who survive the initial month, just under half remain dependent on someone else for help with activities of daily living such as walking, dressing, and bathing. One of the risks in patients with subarachnoid haemorrhage is rebleeding. There are two main ways to try to stop this: operative clipping of the neck of the aneurysm or blocking of the aneurysm from inside by endovascular coiling. This review shows that the number of people who survive and are independent in their daily living is higher after coiling than after clipping. The evidence comes mainly from one large trial.
