Could late rebleeding overturn the superiority of cranial aneurysm coil embolization over clip ligation seen in the International Subarachnoid Aneurysm Trial?

Patrick Mitchell F.R.C.S. 1 , Richard Kerr F.R.C.S. 2 , A. David Mendelow F.R.C.S. 1 and Andy Molyneux F.R.C.R. 2
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  • 2 Neurovascular Research Unit, Nuffield Department of Surgery, University of Oxford and Oxford Radcliffe Hospitals, National Health Service Trust, Radcliffe Infirmary, Oxford; and
  • 1 Department of Neurosurgery, Newcastle General Hospital, Newcastle upon Tyne, United Kingdom
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Object

The present purpose is to define the sensitivity of the superiority of coil embolization observed in the International Subarachnoid Aneurysm Trial (ISAT) according to the rate of late rebleeding over a reasonable range, and to find the range of rebleeding rates for which it may be overturned. In the ISAT, coil embolization appears to be safer than clip ligation at 1 year, and clip occlusion has better long-term efficacy at preventing rebleeding. This leaves open the question of which is better in the longer term.

Methods

The authors calculate the life expectancy of patients following a subarachnoid hemorrhage (SAH) and compare the life expectancy of those who underwent coil embolization with those who underwent clip ligation in the ISAT cohort.

Results

The 1-year poor outcome rate following treatment climbs rapidly with advancing age. A consequence is that the absolute difference between the poor outcome rates after coil embolization and clip occlusion is lower in those < 50 years of age (3.3%) than it is for those > 50 years of age (10.1%). This difference may be enough to give clip application the advantage in the < 40-year-old group despite the small size of the difference in 1-year rebleeding rates thus far observed (0.152%).

Conclusions

When treating ruptured cerebral aneurysms, the advantage of coil embolization over clip ligation cannot be assumed for patients < 40 years old. In this age range the difference in the safety of the 2 procedures is small, and the better long-term protection from SAH afforded by clip placement may give this treatment an advantage in life expectancy for patients < 40 years of age.

Abbreviations used in this paper: ISAT = International Subarachnoid Aneurysm Trial; SAH = subarachnoid hemorrhage; UK = United Kingdom.

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Contributor Notes

Address correspondence to: Patrick Mitchell, F.R.C.S., Department of Neurosurgery, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, United Kingdom. email: patrick.mitchell@ncl.ac.uk.
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