Endovascular Therapy Versus Microsurgical Clipping of Ruptured Wide Neck Aneurysms (EVERRUN Registry): a multicenter, prospective propensity score analysis

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  • 1 Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Texas;
  • | 2 Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona;
  • | 3 Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Health System, New York, New York; and
  • | 4 Yale School of Medicine, New Haven, Connecticut
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OBJECTIVE

Randomized controlled trials have demonstrated the superiority of endovascular therapy (EVT) compared to microsurgery (MS) for ruptured aneurysms suitable for treatment or when therapy is broadly offered to all presenting aneurysms; however, wide neck aneurysms (WNAs) are a challenging subset that require more advanced techniques and warrant further investigation. Herein, the authors sought to investigate a prospective, multicenter WNA registry using rigorous outcome assessments and compare EVT and MS using propensity score analysis (PSA).

METHODS

Untreated, ruptured, saccular WNAs were included in the analysis. A WNA was defined as having a neck ≥ 4 mm or a dome/neck ratio (DNR) < 2. The primary outcome was the modified Rankin Scale (mRS) score at 1 year posttreatment, as assessed by blinded research nurses (good outcome: mRS scores 0–2) and compared using PSA.

RESULTS

The analysis included 87 ruptured aneurysms: 55 in the EVT cohort and 32 in the MS cohort. Demographics were similar in the two cohorts, including Hunt and Hess grade (p = 0.144) and modified Fisher grade (p = 0.475). WNA type inclusion criteria were similar in the two cohorts, with the most common type having a DNR < 2 (EVT 60.0% vs MS 62.5%). More anterior communicating artery aneurysms (27.3% vs 18.8%) and posterior circulation aneurysms (18.2% vs 0.0%) were treated with EVT, whereas more middle cerebral artery aneurysms were treated with MS (34.4% vs 18.2%, p = 0.025). Within the EVT cohort, 43.6% underwent stand-alone coiling, 50.9% balloon-assisted coiling, 3.6% stent-assisted coiling, and 1.8% flow diversion. The 1-year mRS score was assessed in 81 patients (93.1%), and the primary outcome demonstrated no increased risk for a poor outcome with MS compared to EVT (OR 0.43, 95% CI 0.13–1.45, p = 0.177). The durability of MS was higher, as evidenced by retreatment rates of 12.7% and 0% for EVT and MS, respectively (p = 0.04).

CONCLUSIONS

EVT and MS had similar clinical outcomes at 1 year following ruptured WNA treatment. Because of their challenging anatomy, WNAs may represent a population in which EVT’s previously demonstrated superiority for ruptured aneurysm treatment is less relevant. Further investigation into the treatment of ruptured WNAs is warranted.

ABBREVIATIONS

ACA = anterior cerebral artery; ACoA = anterior communicating artery; BAC = balloon-assisted coiling; BRAT = Barrow Ruptured Aneurysm Trial; DAPT = dual antiplatelet therapy; DNR = dome/neck ratio; EVERRUN = Endovascular Therapy Versus Microsurgical Clipping of Ruptured Wide Neck Aneurysms; EVT = endovascular therapy; FD = flow diversion; HH = Hunt and Hess; ICA = internal carotid artery; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage; MCA = middle cerebral artery; mRS = modified Rankin Scale; MS = microsurgery; PSA = propensity score analysis; SAC = stent-assisted coiling; SAH = subarachnoid hemorrhage; WNA = wide neck aneurysm; WNBA = wide neck bifurcation aneurysm.

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  • 1

    Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):12671274.

    • Search Google Scholar
    • Export Citation
  • 2

    McDougall CG, Spetzler RF, Zabramski JM, Partovi S, Hills NK, Nakaji P, Albuquerque FC. The Barrow Ruptured Aneurysm Trial. J Neurosurg. 2012;116(1):135144.

    • Search Google Scholar
    • Export Citation
  • 3

    Fiorella D, Arthur AS, Chiacchierini R, Emery E, Molyneux A, Pierot L. How safe and effective are existing treatments for wide-necked bifurcation aneurysms? Literature-based objective performance criteria for safety and effectiveness. J Neurointerv Surg. 2017;9(12):11971201.

    • Search Google Scholar
    • Export Citation
  • 4

    Pierot L, Costalat V, Moret J, Szikora I, Klisch J, Herbreteau D, et al. Safety and efficacy of aneurysm treatment with WEB: results of the WEBCAST study. J Neurosurg. 2016;124(5):12501256.

    • Search Google Scholar
    • Export Citation
  • 5

    Sirakov S, Sirakov A, Hristov H, Minkin K, Penkov M, Karakostov V. Early experience with a temporary bridging device (Comaneci) in the endovascular treatment of ruptured wide neck aneurysms. J Neurointerv Surg. 2018;10(10):978982.

    • Search Google Scholar
    • Export Citation
  • 6

    O’Connor KP, Strickland AE, Bohnstedt BN. PulseRider use in ruptured basilar apex aneurysms. World Neurosurg. 2019;127:346349.

  • 7

    Mocco J, Snyder KV, Albuquerque FC, Bendok BR, Alan S B, Carpenter JS, et al. Treatment of intracranial aneurysms with the Enterprise stent: a multicenter registry. J Neurosurg. 2009;110(1):3539.

    • Search Google Scholar
    • Export Citation
  • 8

    Sluzewski M, van Rooij WJ, Beute GN, Nijssen PC. Balloon-assisted coil embolization of intracranial aneurysms: incidence, complications, and angiography results. J Neurosurg. 2006;105(3):396399.

    • Search Google Scholar
    • Export Citation
  • 9

    Shapiro M, Babb J, Becske T, Nelson PK. Safety and efficacy of adjunctive balloon remodeling during endovascular treatment of intracranial aneurysms: a literature review. AJNR Am J Neuroradiol. 2008;29(9):17771781.

    • Search Google Scholar
    • Export Citation
  • 10

    Bodily KD, Cloft HJ, Lanzino G, Fiorella DJ, White PM, Kallmes DF. Stent-assisted coiling in acutely ruptured intracranial aneurysms: a qualitative, systematic review of the literature. AJNR Am J Neuroradiol. 2011;32(7):12321236.

    • Search Google Scholar
    • Export Citation
  • 11

    Chalouhi N, Jabbour P, Singhal S, Drueding R, Starke RM, Dalyai RT, et al. Stent-assisted coiling of intracranial aneurysms: predictors of complications, recanalization, and outcome in 508 cases. Stroke. 2013;44(5):13481353.

    • Search Google Scholar
    • Export Citation
  • 12

    Becske T, Brinjikji W, Potts MB, Kallmes DF, Shapiro M, Moran CJ, et al. Long-term clinical and angiographic outcomes following pipeline embolization device treatment of complex internal carotid artery aneurysms: five-year results of the pipeline for uncoilable or failed aneurysms trial. Neurosurgery. 2017;80(1):4048.

    • Search Google Scholar
    • Export Citation
  • 13

    Hanel RA, Kallmes DF, Lopes DK, Nelson PK, Siddiqui A, Jabbour P, et al. Prospective study on embolization of intracranial aneurysms with the pipeline device: the PREMIER study 1 year results. J Neurointerv Surg. 2020;12(1):6266.

    • Search Google Scholar
    • Export Citation
  • 14

    Pierot L, Spelle L, Molyneux A, Byrne J. Clinical and anatomical follow-up in patients with aneurysms treated with the WEB device: 1-year follow-up report in the cumulated population of 2 prospective, multicenter series (WEBCAST and French Observatory). Neurosurgery. 2016;78(1):133141.

    • Search Google Scholar
    • Export Citation
  • 15

    Raj R, Rautio R, Pekkola J, Rahi M, Sillanpää M, Numminen J. Treatment of ruptured intracranial aneurysms using the Woven EndoBridge device: a two-center experience. World Neurosurg. 2019;123:e709e716.

    • Search Google Scholar
    • Export Citation
  • 16

    Spiotta AM, Derdeyn CP, Tateshima S, Mocco J, Crowley RW, Liu KC, et al. Results of the ANSWER trial using the PulseRider for the treatment of broad-necked, bifurcation aneurysms. Neurosurgery. 2017;81(1):5665.

    • Search Google Scholar
    • Export Citation
  • 17

    Lylyk P, Chudyk J, Bleise C, Sahl H, Pérez MA, Henkes H, Bhogal P. The pCONus2 neck-bridging device: early clinical experience and immediate angiographic results. World Neurosurg. 2018;110:e766e775.

    • Search Google Scholar
    • Export Citation
  • 18

    Mühl-Benninghaus R, Simgen A, Reith W, Yilmaz U. The Barrel stent: new treatment option for stent-assisted coiling of wide-necked bifurcation aneurysms-results of a single-center study. J Neurointerv Surg. 2017;9(12):12191222.

    • Search Google Scholar
    • Export Citation
  • 19

    Pierot L, Cognard C, Anxionnat R, Ricolfi F. Remodeling technique for endovascular treatment of ruptured intracranial aneurysms had a higher rate of adequate postoperative occlusion than did conventional coil embolization with comparable safety. Radiology. 2011;258(2):546553.

    • Search Google Scholar
    • Export Citation
  • 20

    Hetts SW, Turk A, English JD, Dowd CF, Mocco J, Prestigiacomo C, et al. Stent-assisted coiling versus coiling alone in unruptured intracranial aneurysms in the matrix and platinum science trial: safety, efficacy, and mid-term outcomes. AJNR Am J Neuroradiol. 2014;35(4):698705.

    • Search Google Scholar
    • Export Citation
  • 21

    Fan L, Tan X, Xiong Y, Zheng K, Li Z, Liu D, et al. Stent-assisted coiling versus coiling alone of ruptured anterior communicating artery aneurysms: a single-center experience. Clin Neurol Neurosurg. 2016;144:96100.

    • Search Google Scholar
    • Export Citation
  • 22

    Mascitelli JR, Lawton MT, Hendricks BK, Nakaji P, Zabramski JM, Spetzler RF. Analysis of wide-neck aneurysms in the Barrow Ruptured Aneurysm Trial. Neurosurgery. 2018;85(5):622631.

    • Search Google Scholar
    • Export Citation
  • 23

    Hendricks BK, Yoon JS, Yaeger K, Kellner CP, Mocco J, De Leacy RA, et al. Wide-neck aneurysms: systematic review of the neurosurgical literature with a focus on definition and clinical implications. J Neurosurg. 2020;133(1):159165.

    • Search Google Scholar
    • Export Citation
  • 24

    Janssen PM, Visser NA, Dorhout Mees SM, Klijn CJ, Algra A, Rinkel GJ. Comparison of telephone and face-to-face assessment of the modified Rankin Scale. Cerebrovasc Dis. 2010;29(2):137139.

    • Search Google Scholar
    • Export Citation
  • 25

    Roy D, Milot G, Raymond J. Endovascular treatment of unruptured aneurysms. Stroke. 2001;32(9):19982004.

  • 26

    Bsat S, Bsat A, Tamim H, Chanbour H, Alomari SO, Houshiemy MNE, et al. Safety of stent-assisted coiling for the treatment of wide-necked ruptured aneurysm: a systematic literature review and meta-analysis of prevalence. Interv Neuroradiol. 2020;26(5):547556.

    • Search Google Scholar
    • Export Citation
  • 27

    Roh H, Kim J, Bae H, Chong K, Kim JH, Suh SI, et al. Comparison of stent-assisted and no-stent coil embolization for safety and effectiveness in the treatment of ruptured intracranial aneurysms. J Neurosurg. 2020;133(3):814820.

    • Search Google Scholar
    • Export Citation
  • 28

    Cai K, Zhang Y, Shen L, Ni Y, Ji Q. Comparison of stent-assisted coiling and balloon-assisted coiling in the treatment of ruptured wide-necked intracranial aneurysms in the acute period. World Neurosurg. 2016;96:316321.

    • Search Google Scholar
    • Export Citation
  • 29

    Cagnazzo F, di Carlo DT, Cappucci M, Lefevre PH, Costalat V, Perrini P. Acutely ruptured intracranial aneurysms treated with flow-diverter stents: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2018;39(9):16691675.

    • Search Google Scholar
    • Export Citation
  • 30

    Kim S, Choi JH, Kang M, Cha JK, Huh JT. Safety and efficacy of intravenous tirofiban as antiplatelet premedication for stent-assisted coiling in acutely ruptured intracranial aneurysms. AJNR Am J Neuroradiol. 2016;37(3):508514.

    • Search Google Scholar
    • Export Citation
  • 31

    Samaniego EA, Gibson E, Nakagawa D, Ortega-Gutierrez S, Zanaty M, Roa JA, et al. Safety of tirofiban and dual antiplatelet therapy in treating intracranial aneurysms. Stroke Vasc Neurol. 2019;4(1):3642.

    • Search Google Scholar
    • Export Citation
  • 32

    Ospel JM, Brouwer P, Dorn F, Arthur A, Jensen ME, Nogueira R, et al. Antiplatelet management for stent-assisted coiling and flow diversion of ruptured intracranial aneurysms: a DELPHI consensus statement. AJNR Am J Neuroradiol. 2020;41(10):18561862.

    • Search Google Scholar
    • Export Citation
  • 33

    Howard BM, Frerich JM, Madaelil TP, Dion JE, Tong FC, Cawley CM, Grossberg JA. ‘Plug and pipe’ strategy for treatment of ruptured intracranial aneurysms. J Neurointerv Surg. 2019;11(1):4348.

    • Search Google Scholar
    • Export Citation
  • 34

    Crinnion W, Bhogal P, Makalanda HLD, Wong K, Arthur A, Cognard C, et al. The Woven Endobridge as a treatment for acutely ruptured aneurysms: a review of the literature. Interv Neuroradiol. 2021;27(5):602608.

    • Search Google Scholar
    • Export Citation
  • 35

    Sirakov A, Minkin K, Penkov M, Ninov K, Karakostov V, Sirakov S. Comaneci-assisted coiling as a treatment option for acutely ruptured wide neck cerebral aneurysm: case series of 118 patients. Neurosurgery. 2020;87(6):11481156.

    • Search Google Scholar
    • Export Citation

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