Endovascular coiling versus neurosurgical clipping for people with aneurysmal subarachnoid haemorrhage

Antti Lindgren; Mervyn DI Vergouwen; Irene van der Schaaf; Ale Algra; Marieke Wermer; Mike J Clarke; Gabriel JE Rinkel

doi:10.1002/14651858.CD003085.pub3

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Figure 1

Study flow diagram. RCT: randomised controlled trial.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 Poor outcome: death or dependence in daily activities, Outcome 1 Death or dependency at 2–3 months.

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Analysis 1.2

Comparison 1 Poor outcome: death or dependence in daily activities, Outcome 2 Death or dependency at 12 months after subarachnoid haemorrhage.

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Analysis 1.3

Comparison 1 Poor outcome: death or dependence in daily activities, Outcome 3 Worst‐case scenario at 12 months.

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Analysis 1.4

Comparison 1 Poor outcome: death or dependence in daily activities, Outcome 4 Death or dependency at 5 years.

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Analysis 1.5

Comparison 1 Poor outcome: death or dependence in daily activities, Outcome 5 Death or dependency at 10 years.

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Analysis 2.1

Comparison 2 Death from any cause, Outcome 1 Death from any cause 2–3 months.

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Analysis 2.2

Comparison 2 Death from any cause, Outcome 2 Death from any cause between randomisation and 1 year after SAH.

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Analysis 2.3

Comparison 2 Death from any cause, Outcome 3 Death from any cause up to 5 years.

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Analysis 2.4

Comparison 2 Death from any cause, Outcome 4 Death from any cause up to 10 years.

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Analysis 3.1

Comparison 3 Delayed cerebral ischaemia (DCI), Outcome 1 DCI at 2–3 months.

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Analysis 4.1

Comparison 4 Rebleeding, Outcome 1 Rebleed before treatment.

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Analysis 4.2

Comparison 4 Rebleeding, Outcome 2 Rebleed postprocedure up to 1 year.

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Analysis 4.3

Comparison 4 Rebleeding, Outcome 3 Rebleed postprocedure up to 3 months.

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Analysis 4.4

Comparison 4 Rebleeding, Outcome 4 Rebleed postprocedure up to 5 years.

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Analysis 4.5

Comparison 4 Rebleeding, Outcome 5 Rebleed postprocedure up to 10 years.

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Analysis 5.1

Comparison 5 Complications from intervention, Outcome 1 Complications from intervention.

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Analysis 6.1

Comparison 6 Degree of obliteration, Outcome 1 Non‐complete obliteration after 1 year.

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Analysis 6.2

Comparison 6 Degree of obliteration, Outcome 2 < 90% occlusion after 1 year.

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Analysis 7.1

Comparison 7 Subgroup analysis: aneurysm location, Outcome 1 Poor outcome at 12 months: posterior and anterior circulation.

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Summary of findings for the main comparison. Endovascular coiling compared with neurosurgical clipping for subarachnoid haemorrhage

Endovascular coiling compared with neurosurgical clipping for subarachnoid haemorrhage
Patient or population: people with subarachnoid haemorrhage from a ruptured intracranial aneurysm Settings: tertiary care Intervention: endovascular coiling of aneurysm Comparison: neurosurgical clipping of aneurysm
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Neurosurgical clipping	Endovascular coiling
Poor outcome: death or dependence in daily activities (12 months)	Study population		RR 0.77 (0.67 to 0.87)	2429 (4 RCTs)	⊕⊕⊕⊝ Moderate^a	—
	366 per 1000	281 per 1000 (245 to 318)
Poor outcome (death or dependence) (10 years)	Study population		RR 0.81 (0.70 to 0.92)	1316 (1 RCT)	⊕⊕⊝⊝^a,b Low	Based on subgroup of participants in 1 large RCT only
	430 per 1000	348 per 1000 (301 to 395)
Death from any cause (12 months)	Study population		RR 0.80 (0.63 to 1.02)	2429 (4 RCTs)	⊕⊕⊕⊝ Moderate^a	—
	154 per 1000	123 per 1000 (97 to 157)
Delayed cerebral ischaemia (2–3 months)	Study population		RR 0.84 (0.74 to 0.96)	2450 (4 RCTs)	⊕⊕⊕⊝ Moderate^a	—
	384 per 1000	322 per 1000 (284 to 368 )
Rebleeding postprocedure up to 1 year	Study population		RR 1.83 (1.04 to 3.23)	2458 (4 RCTs)	⊕⊕⊕⊕ High	—
	21 per 1000	38 per 1000 (21 to 67)
Rebleeding postprocedure up to 10 years	Study population		RR 2.69 (1.50 to 4.81)	1323 (1 RCT)	⊕⊕⊝⊝^a,b Low	Based on 1 large RCT only
	22 per 1000	61 per 1000 (34 to 109)
Complications from the intervention	Study population		RR 1.05 (0.44 to 2.53)	129 (2 RCTs)	⊕⊕⊝⊝^c Low	Based on 2 small RCTs only
	235 per 1000	246 per 1000 (103 to 594)
The basis for the assumed risk* (e.g. the median control group risk across studies) is derived from the studies included in the meta‐analysis. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio.
GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^aDowngraded one level due to indirectness of evidence: participants in poor condition on admission under‐represented in the largest RCT. ^bDowngraded one level due to risk of bias: long‐term outcome data available for only a subgroup of participants. ^cDowngraded two levels due to risk of bias: underpowered due to data availability from only two small trials, unclear definition of complication from intervention.

Summary of findings for the main comparison. Endovascular coiling compared with neurosurgical clipping for subarachnoid haemorrhage

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Table 1. Angiographic occlusion on follow‐up angiography during first year post‐treatment

Number of participants per treatment	Extent of occlusion
Number of participants per treatment	100%	90% to 100%	< 90%
ISAT 2002
Endovascular coiling: 881	584 (66%)	228 (26%)	69 (8%)
Neurosurgical clipping: 450	370 (82%)	55 (12%)	25 (6%)
Koivisto 2000
Endovascular coiling: 52	40 (77%)	10 (19%)	2 (4%)
Neurosurgical clipping: 57	49 (86%)	7 (12%)	1 (2%)
Total
Endovascular coiling: 933	624 (67%)	238 (26%)	71 (8%)
Neurosurgical clipping: 507	419 (83%)	62 (12%)	26 (5%)

Table 1. Angiographic occlusion on follow‐up angiography during first year post‐treatment

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Comparison 1. Poor outcome: death or dependence in daily activities

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death or dependency at 2–3 months Show forest plot	3	2257	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.63, 0.81]

2 Death or dependency at 12 months after subarachnoid haemorrhage Show forest plot	4	2429	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.67, 0.87]

3 Worst‐case scenario at 12 months Show forest plot	4	2458	Risk Ratio (M‐H, Fixed, 95% CI)	0.80 [0.71, 0.91]

4 Death or dependency at 5 years Show forest plot	1	1724	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.75, 1.01]

5 Death or dependency at 10 years Show forest plot	1	1316	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.70, 0.92]

Comparison 1. Poor outcome: death or dependence in daily activities

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Comparison 2. Death from any cause

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Death from any cause 2–3 months Show forest plot	3	2257	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.66, 1.18]

2 Death from any cause between randomisation and 1 year after SAH Show forest plot	4	2429	Risk Ratio (M‐H, Fixed, 95% CI)	0.80 [0.63, 1.02]

3 Death from any cause up to 5 years Show forest plot	1	2087	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.61, 0.98]

4 Death from any cause up to 10 years Show forest plot	1	1644	Risk Ratio (M‐H, Fixed, 95% CI)	0.78 [0.64, 0.96]

Comparison 2. Death from any cause

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Comparison 3. Delayed cerebral ischaemia (DCI)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 DCI at 2–3 months Show forest plot	4	2450	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.74, 0.96]

Comparison 3. Delayed cerebral ischaemia (DCI)

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Comparison 4. Rebleeding

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Rebleed before treatment Show forest plot	3	2272	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.37, 1.12]

2 Rebleed postprocedure up to 1 year Show forest plot	4	2458	Risk Ratio (M‐H, Fixed, 95% CI)	1.83 [1.04, 3.23]

3 Rebleed postprocedure up to 3 months Show forest plot	3	2272	Risk Ratio (M‐H, Fixed, 95% CI)	2.66 [0.71, 10.00]

4 Rebleed postprocedure up to 5 years Show forest plot	1	1448	Risk Ratio (M‐H, Fixed, 95% CI)	2.75 [1.51, 5.02]

5 Rebleed postprocedure up to 10 years Show forest plot	1	1323	Risk Ratio (M‐H, Fixed, 95% CI)	2.69 [1.50, 4.81]

Comparison 4. Rebleeding

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Comparison 5. Complications from intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Complications from intervention Show forest plot	2	129	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.44, 2.53]

Comparison 5. Complications from intervention

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Comparison 6. Degree of obliteration

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Non‐complete obliteration after 1 year Show forest plot	3	1626	Risk Ratio (M‐H, Fixed, 95% CI)	2.02 [1.65, 2.47]

2 < 90% occlusion after 1 year Show forest plot	2	1440	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [0.93, 2.21]

Comparison 6. Degree of obliteration

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Comparison 7. Subgroup analysis: aneurysm location

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Poor outcome at 12 months: posterior and anterior circulation Show forest plot	2	2226	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.66, 0.88]

1.1 Poor outcome at 12 months: posterior circulation	2	69	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.19, 0.92]
1.2 Poor outcome at 12 months: anterior circulation	2	2157	Risk Ratio (M‐H, Fixed, 95% CI)	0.78 [0.68, 0.90]

Comparison 7. Subgroup analysis: aneurysm location

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