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June 1, 1999

Surgical and endovascular treatment of unruptured cerebral aneurysms at university hospitals

June 1, 1999 issue
52 (9) 1799

Abstract

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.

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References

1.
Johnston SC, Selvin S, Gress DR. The burden, trends, and demographics of mortality from subarachnoid hemorrhage. Neurology 1998;50:1413–1418.
2.
King JT Jr, Berlin JA, Flamm ES. Morbidity and mortality from elective surgery for asymptomatic, unruptured, intracranial aneurysms : a meta-analysis. J Neurosurg 1994;81:837–842.
3.
King JT Jr, Glick HA, Mason TJ, Flamm ES. Elective surgery for asymptomatic, unruptured, intracranial aneurysms : a cost-effectiveness analysis. J Neurosurg 1995;83:403–412.
4.
van Crevel H, Habbema JD, Braakman R. Decision analysis of the management of incidental intracranial saccular aneurysms. Neurology 1986;36:1335–1339.
5.
Chang HS, Kirino T. Quantification of operative benefit for unruptured cerebral aneurysms : a theoretical approach. J Neurosurg 1995;83:413–420.
6.
Leblanc R, Worsley KJ. Surgery of unruptured, asymptomatic aneurysms : a decision analysis. Can J Neurol Sci 1995;22:30–35.
7.
Wirth FP, Laws ER Jr, Piepgras D, Scott RM. Surgical treatment of incidental intracranial aneurysms. Neurosurgery 1983;12:507–511.
8.
Schievink WI. Intracranial aneurysms. N Engl J Med 1997;336:28–40.
9.
Raaymakers TW, Rinkel GJ, Limburg M, Algra A. Mortality and morbidity of surgery for unruptured intracranial aneurysms : a meta-analysis. Stroke 1998;29:1531–1538.
10.
Solomon RA, Mayer SA, Tarmey JJ. Relationship between the volume of craniotomies for cerebral aneurysm performed at New York state hospitals and in-hospital mortality. Stroke 1996;27:13–17.
11.
Guglielmi G, Vinuela F, Sepetka I, Macellari V. Electrothrombosis of saccular aneurysms via endovascular approach. Part 1 : electrochemical basis, technique, and experimental results. J Neurosurg 1991;75:1–7.
12.
Guglielmi G, Vinuela F, Dion J, Duckwiler G. Electrothrombosis of saccular aneurysms via endovascular approach. Part 2 : preliminary clinical experience. J Neurosurg 1991;75:8–14.
13.
Bryan RN, Rigamonti D, Mathis JM. The treatment of acutely ruptured cerebral aneurysms : endovascular therapy versus surgery. AJNR Am J Neuroradiol 1997;18:1826–1830.
14.
Brilstra EH, Rinkel GJE, van der Graaf Y, van Rooij WJJ, Algra A. Treatment of intracranial aneurysms by embolization with coils : a systemic review. Stroke 1999;30:470–476.
15.
Solomon RA, Fink ME, Pile-Spellman J. Surgical management of unruptured intracranial aneurysms. J Neurosurg 1994;80:440–446.
16.
Member Statistics. In: University Health Systems Consortium, 1998. http://www.uhc.edu/about/memstats.html
17.
Diggle PJ, Liang KY, Zeger SL. Analysis of longitudinal data. Oxford Statistical Science Series, vol. 13. Oxford: Clarendon Press, 1994.
18.
Poses RM, Smith WR, McClish DK, Anthony M. Controlling for confounding by indication for treatment. Are administrative data equivalent to clinical data? Med Care 1995;33 (suppl 4):AS36–AS46.
19.
Khanna RK, Malik GM, Qureshi N. Predicting outcome following surgical treatment of unruptured intracranial aneuhrysms : a proposed grading system. J Neurosurg 1996;84:49–54.
20.
Guglielmi G, Vinuela F, Duckwiler G,et al. Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils. J Neurosurg 1992;77:515–524.
21.
Malisch TW, Guglielmi G, Vinuela F, et al. Intracranial aneurysms treated with the Guglielmi detachable coil: midterm clinical results in a consecutive series of 100 patients. J Neurosurg 1997;87:176–183.
22.
Halbach VV, Higashida RT, Dowd CF, et al. The efficacy of endosaccular aneurysm occlusion in alleviating neurological deficits produced by mass effect. J Neurosurg 1994;80:659–666.
23.
The International Study of Unruptured Intracranial Aneurysms Investigators.Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. N Engl J Med 1998;339:1725–1733.
24.
Drake CG, Vanderlinden RG. The late consequences of incomplete surgical treatment of cerebral aneurysms. J Neurosurg 1967;27:226–238.
25.
Graves VB, Strother CM, Duff TA, Perl J. II. Early treatment of ruptured aneurysms with Guglielmi detachable coils : effect on subsequent bleeding. Neurosurgery 1995;37:640–647.
26.
Casasco AE, Aymard A, Gobin YP, et al. Selective endovascular treatment of 71 intracranial aneurysms with platinum coils. J Neurosurg 1993;79:3–10.
27.
Jane JA, Kassell NF, Torner JC, Winn HR. The natural history of aneurysms and arteriovenous malformations. J Neurosurg 1985;62:321–323.
28.
Vinuela F, Duckwiler G, Mawad M. Guglielmi detachable coil embolization of acute intracranial aneurysm : perioperative anatomical and clinical outcome in 403 patients. J Neurosurg 1997;86:475–482.
29.
McDougall CG, Halbach VV, Dowd CF, Higashida RT, Larsen DW, Hieshima GB. Endovascular treatment of basilar tip aneurysms using electrolytically detachable coils. J Neurosurg 1996;84:393–399.
30.
Kassell NF, Torner JC, Haley EC Jr, Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1 : overall management results. J Neurosurg 1990;73:18–36.
31.
Eskridge JM, Song JK. Endovascular embolization of 150 basilar tip aneurysms with Guglielmi detachable coils : results of the Food and Drug Administration multicenter clinical trial. J Neurosurg 1998;89:81–86.

Information & Authors

Information

Published In

Neurology®
Volume 52Number 9June 1, 1999
Pages: 1799
PubMed: 10371526

Publication History

Received: January 18, 1999
Accepted: March 20, 1999
Published online: June 1, 1999
Published in print: June 1, 1999

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Authors

Affiliations & Disclosures

S. Claiborne Johnston, MD, MPH
From the Neurovascular ServiceDepartment of Neurology (Drs. Johnston and Gress), Institute for Health Policy Studies (Dr. Dudley), and Department of Quality Improvement (L. Ono), University of California, San Francisco, CA.
R. Adams Dudley, MD, MBA
From the Neurovascular ServiceDepartment of Neurology (Drs. Johnston and Gress), Institute for Health Policy Studies (Dr. Dudley), and Department of Quality Improvement (L. Ono), University of California, San Francisco, CA.
Daryl R. Gress, MD
From the Neurovascular ServiceDepartment of Neurology (Drs. Johnston and Gress), Institute for Health Policy Studies (Dr. Dudley), and Department of Quality Improvement (L. Ono), University of California, San Francisco, CA.
Linda Ono, BHA, ART
From the Neurovascular ServiceDepartment of Neurology (Drs. Johnston and Gress), Institute for Health Policy Studies (Dr. Dudley), and Department of Quality Improvement (L. Ono), University of California, San Francisco, CA.

Notes

Address correspondence and reprint requests to Dr. S. Claiborne Johnston, Department of Neurology, Box 0114, University of California, San Francisco, 505 Parnassus Ave., San Francisco, CA 94143-0114; e-mail: [email protected]

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