title: Short term outcomes following clipping and coiling of ruptured intracranial aneurysms: does some of the benefit of coiling stem from less procedural impact on deranged physiology at presentation?
abstract: BACKGROUND
  Endovascular coiling (EVC) has been shown to yield superior clinical outcomes to surgical clipping (SC) in the treatment of ruptured cerebral aneurysms. The reasons for these differences remain obscure. We aimed to assess outcomes of EVC and SC relative to baseline physiological derangement.
  
  
  METHODS
  This was an exploratory analysis of prospectively collected trial data. Physiological derangement was assessed using the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system. Other contributory variables such as age, World Federation of Neurosurgical Societies (WFNS) grade, and development of complications, including hydrocephalus and vasospasm, were included in the analysis. Clinical outcome was independently assessed at 90 days using the modified Rankin Scale (mRS). Hospital stay, ventilated days, and total norepinephrine dose were also used as secondary outcomes. Multivariate analysis was performed using binary logistic regression.
  
  
  RESULTS
  EVC was performed in 69 patients and SC in 66 patients. More profound physiological derangement (APACHE II score >15) was the strongest predictor of poor outcome in the overall cohort (OR 17.80, 95% CI 4.78 to 66.21, p<0.0001). For those with more deranged physiology (APACHE II score>15; 59 patients), WFNS grade ≥4 (OR 6.74, 1.43 to 31.75) and SC (OR 6.33, 1.27 to 31.38) were significant predictors of poor outcome (p<0.05). Favorable outcome (mRS 0-2) was seen in 11% of SC patients compared with 38% of EVC patients in this subgroup. SC patients had significantly increased total norepinephrine dose, ventilated days, and hospital stay (p<0.05).
  
  
  CONCLUSIONS
  More profound physiological derangement at baseline is a strong predictor of eventual poor outcome, and outcomes for patients with more profound baseline physiological derangement may be improved if undergoing a coiling procedure.
authors.affiliation: Department of Radiology, Royal North Shore Hospital, Sydney, New South Wales, Australia.
authors.forename: Alex M
authors.initials: AM
authors.lastname: Mortimer
authors.affiliation: Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia.
authors.forename: Celia
authors.initials: C
authors.lastname: Bradford
authors.affiliation: Department of Radiology, Royal North Shore Hospital, Sydney, New South Wales, Australia.
authors.forename: Brendan
authors.initials: B
authors.lastname: Steinfort
authors.affiliation: Department of Radiology, Royal North Shore Hospital, Sydney, New South Wales, Australia.
authors.forename: Ken
authors.initials: K
authors.lastname: Faulder
authors.affiliation: Department of Neurosurgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.
authors.forename: Nazih
authors.initials: N
authors.lastname: Assaad
authors.affiliation: Department of Radiology, Royal North Shore Hospital, Sydney, New South Wales, Australia.
authors.forename: Timothy
authors.initials: T
authors.lastname: Harrington
mesh_terms: D018806:APACHE; D000368:Aged; D017542:Aneurysm, Ruptured / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D002986:Clinical Trials as Topic / Q000379:methods; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D011446:Prospective Studies; D013525:Surgical Instruments; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aneurysm; Coil; Complication; Intervention