title: Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial.
abstract: OBJECTIVE The Barrow Ruptured Aneurysm Trial (BRAT) is a prospective, randomized trial in which treatment with clipping was compared to treatment with coil embolization. Patients were randomized to treatment on presentation with any nontraumatic subarachnoid hemorrhage (SAH). Because all other randomized trials comparing these 2 types of treatments have been limited to saccular aneurysms, the authors analyzed the current BRAT data for this subgroup of lesions. METHODS The primary BRAT analysis included all sources of SAH: nonaneurysmal lesions; saccular, blister, fusiform, and dissecting aneurysms; and SAHs from an aneurysm associated with either an arteriovenous malformation or a fistula. In this post hoc review, the outcomes for the subgroup of patients with saccular aneurysms were further analyzed by type of treatment. The extent of aneurysm obliteration was adjudicated by an independent neuroradiologist not involved in treatment. RESULTS Of the 471 patients enrolled in the BRAT, 362 (77%) had an SAH from a saccular aneurysm. Patients with saccular aneurysms were assigned equally to the clipping and the coiling cohorts (181 each). In each cohort, 3 patients died before treatment and 178 were treated. Of the 178 clip-assigned patients with saccular aneurysms, 1 (1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. There was no statistically significant difference in poor outcome (modified Rankin Scale score > 2) between these 2 treatment arms at any recorded time point during 6 years of follow-up. After the initial hospitalization, 1 of 241 (0.4%) clipped saccular aneurysms and 21 of 115 (18%) coiled saccular aneurysms required retreatment (p < 0.001). At the 6-year follow-up, 95% (95/100) of the clipped aneurysms were completely obliterated, compared with 40% (16/40) of the coiled aneurysms (p < 0.001). There was no difference in morbidity between the 2 treatment groups (p = 0.10). CONCLUSIONS In the subgroup of patients with saccular aneurysms enrolled in the BRAT, there was no significant difference between modified Rankin Scale outcomes at any follow-up time in patients with saccular aneurysms assigned to clipping compared with those assigned to coiling (intent-to-treat analysis). At the 6-year follow-up evaluation, rates of retreatment and complete aneurysm obliteration significantly favored patients who underwent clipping compared with those who underwent coiling. Clinical trial registration no.: NCT01593267 (clinicaltrials.gov).
authors.affiliation: Departments of1Neurosurgery and.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Spetzler
authors.affiliation: Departments of1Neurosurgery and.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Zabramski
authors.affiliation: Departments of1Neurosurgery and.
authors.forename: Cameron G
authors.initials: CG
authors.lastname: McDougall
authors.affiliation: Departments of1Neurosurgery and.
authors.forename: Felipe C
authors.initials: FC
authors.lastname: Albuquerque
authors.affiliation: 3Department of Neurology, University of California, San Francisco, California.
authors.forename: Nancy K
authors.initials: NK
authors.lastname: Hills
authors.affiliation: 2Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Wallace
authors.affiliation: Departments of1Neurosurgery and.
authors.forename: Peter
authors.initials: P
authors.lastname: Nakaji
mesh_terms: D000783:Aneurysm / Q000209:etiology / Q000601:surgery*; D017542:Aneurysm, Ruptured / Q000209:etiology / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D019635:Neurosurgical Procedures / Q000379:methods; D012086:Reoperation; D013345:Subarachnoid Hemorrhage / Q000209:etiology / Q000601:surgery*; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods
keywords: AVM = arteriovenous malformation; BRAT; BRAT = Barrow Ruptured Aneurysm Trial; CARAT = Cerebral Aneurysm Rerupture After Treatment; ISAT; ISAT = International Subarachnoid Aneurysm Trial; SAH; SAH = subarachnoid hemorrhage; clip occlusion; coil embolization; intracranial aneurysm; mRS = modified Rankin Scale; randomized trial; saccular aneurysms; subarachnoid hemorrhage; vascular disorders