Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms. A prospective randomized study.
OBJECTIVE
This prospective study was conducted to compare the outcomes of surgical clipping and endovascular treatment in acute (<72 hours) aneurysmal subarachnoid hemorrhage (SAH).


METHODS
One hundred nine consecutive patients were randomly assigned to either surgical (n=57) or endovascular (n=52) treatment. Clinical and neuropsychological outcome was assessed at 3 and 12 months after treatment; MRI of the brain was performed at 12 months. Follow-up angiography was scheduled after clipping and 3 and 12 months after endovascular treatment.


RESULTS
One year postoperatively, 43/41 (surgical/endovascular) patients had good or moderate recovery, 5/4 had severe disability or were in a vegetative state, and 9/7 had died (NS) according to intention to treat. Patients with good clinical recovery did not differ in their neuropsychological test scores. Symptomatic vasospasm (OR 2.47; 95% CI 1.45 to 4.19; P<0.001), poorer Hunt and Hess grade (OR 2.50; 95% CI 1.31 to 4.75; P=0.005), need for permanent shunt (OR 8.90; 95% CI 1.80 to 44.15; P=0.008), and larger size of the aneurysm (OR 1. 22; 95% CI 1.02 to 1.45; P=0.032) independently predicted worsened clinical outcome regardless of the treatment modality. In MRI, superficial brain retraction deficits (P<0.001) and ischemic lesions in the territory of the ruptured aneurysm (P=0.025) were more frequent in the surgical group. Kaplan-Meier analysis (mean+/-SD follow-up 39+/-18 months) revealed equal survival in both treatment groups. No late rebleedings have occurred.


CONCLUSIONS
One-year clinical and neuropsychological outcomes seem comparable after early surgical and endovascular treatment of ruptured intracranial aneurysms. The long-term efficacy of endovascular treatment in preventing rebleeding remains open.
Koivisto
T
T
Departments of Neurosurgery, Kuopio University Hospital, Kuopio, Finland. timo.koivisto@kuh.fi
Vanninen
R
R
Hurskainen
H
H
Saari
T
T
Hernesniemi
J
J
Vapalahti
M
M
D017542:Aneurysm, Ruptured / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D001921:Brain / Q000098:blood supply / Q000473:pathology / Q000601:surgery; D002533:Cerebral Angiography; D018592:Cross-Over Studies; D004621:Embolization, Therapeutic / Q000009:adverse effects; D005500:Follow-Up Studies; D023261:Glasgow Outcome Scale; D006801:Humans; D002532:Intracranial Aneurysm / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016015:Logistic Models; D008279:Magnetic Resonance Imaging; D009483:Neuropsychological Tests; D016017:Odds Ratio; D011446:Prospective Studies; D020127:Recovery of Function; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D016019:Survival Analysis; D016896:Treatment Outcome