Letter to the Editor. Clip, clip, pass: real-world data and middle cerebral artery aneurysms

View More View Less
  • 1 Mayo Clinic, Rochester, MN; and
  • 2 Barrow Neurological Institute, St. Joseph’s Hospital, Phoenix, AZ
Free access

If the inline PDF is not rendering correctly, you can download the PDF file here.

TO THE EDITOR: We read with great interest the timely and provocative article by Berro et al.,1 an exciting work that provides important and novel evidence in support of the conclusion that middle cerebral artery (MCA) aneurysms are and should remain surgical lesions (Berro DH, L’Allinec V, Pasco-Papon A, et al: Clip-first policy versus coil-first policy for the exclusion of middle cerebral artery aneurysms. J Neurosurg [epub ahead of print September 20, 2019. DOI: 10.3171/2019.5.JNS19373]).

By leveraging established “clip first” and “coil first” protocols at sister institutions, applied to paired series of consecutive patients, the authors have executed a clever study design that functions as a form of surrogate randomization. The benefits of this approach are apparent in the “intention-to-treat” analysis, which provides real-world data that allow practical conclusions to be drawn within a relatively rigorous statistical framework.

The authors have posed the question, “Does an institution that practices a clip-first policy achieve superior clinical outcomes to one that practices under a coil-first policy, allowing for clinically determined crossover between techniques in rare, appropriately selected circumstances?”

The answer is a compelling yes, supported in their study by evidence with a higher degree of reliability and certainty than essentially all preceding observational studies and in alignment with the highest-quality evidence from clinical trials in this space—including the Barrow Ruptured Aneurysm Trial (BRAT).3–5

The study also highlights two vulnerabilities of endovascular coiling as a primary modality for MCA aneurysms. First, the alarmingly low rate of complete radiographic occlusion in the endovascular group (31%) demonstrates that a large fraction of patients with coiled MCA aneurysms remain exposed to an unacceptable risk of rupture or rebleeding. Additionally, patients who underwent coiling were also significantly more likely to require retreatment and were therefore subject to the intrinsic risks of two procedures, the second of which was markedly higher risk, as a repeat intervention.

Although neurosurgery is evolving beyond rigid “clip/coil first” policies, we have learned that the safer default treatment for patients with MCA aneurysms is clipping. As such, the findings reported by Berro et al. provide a key ballast against the concerning trend we have noted—particularly in Europe—of centers adopting universal coil-first postures toward intracranial aneurysms, independent of location, morphology, or other predictive factors. This attitude is informed in part by a 2018 Cochrane review, which argued that patients with favorable hemorrhage grades should preferentially undergo coiling. Unfortunately, the evidence-based analysis reproduces the intrinsic limitations and biases of its component studies—namely, that the granularity between patient cohorts (e.g., MCA location) is inadequate.2 This vulnerability is highlighted by numerous other analyses, such as single-center studies, clinical trials including the BRAT, and at least 2 other large-scale systematic reviews that appropriately stratified cases by aneurysm location, all of which highlighted key outcomes in clinical, radiographic, or durability domains that support the superiority of neurosurgical clipping for the treatment of MCA aneurysms.3,5–7

We congratulate the authors for their outstanding work, which demonstrates a creative and compelling mode for infusing clinical research in neurosurgery with additional rigor and reinforces the fundamental superiority of open clipping for MCA aneurysms.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Berro DH, L’Allinec V, Pasco-Papon A, Emery E, Berro M, Barbier C, : Clip-first policy versus coil-first policy for the exclusion of middle cerebral artery aneurysms. J Neurosurg [epub ahead of print September 20, 2019. DOI: 10.3171/2019.5.JNS19373]

    • Search Google Scholar
    • Export Citation
  • 2

    Lindgren A, Vergouwen MDI, van der Schaaf I, Algra A, Wermer M, Clarke MJ, : Endovascular coiling versus neurosurgical clipping for people with aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 8:CD003085, 2018

    • Search Google Scholar
    • Export Citation
  • 3

    Mooney MA, Simon ED, Brigeman S, Nakaji P, Zabramski JM, Lawton MT, : Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial. J Neurosurg 130:895901, 2018

    • Search Google Scholar
    • Export Citation
  • 4

    Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Nakaji P, : Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg [epub ahead of print March 8, 2019. DOI: 10.3171/2018.8.JNS181846]

    • Search Google Scholar
    • Export Citation
  • 5

    Spetzler RF, Zabramski JM, McDougall CG, Albuquerque FC, Hills NK, Wallace RC, : Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg 128:120125, 2018

    • Search Google Scholar
    • Export Citation
  • 6

    Steklacova A, Bradac O, Charvat F, De Lacy P, Benes V: “Clip first” policy in management of intracranial MCA aneurysms: single-centre experience with a systematic review of literature. Acta Neurochir 158:533546, 2016

    • Search Google Scholar
    • Export Citation
  • 7

    Zijlstra IA, Verbaan D, Majoie CB, Vandertop P, van den Berg R: Coiling and clipping of middle cerebral artery aneurysms: a systematic review on clinical and imaging outcome. J Neurointerv Surg 8:2429, 2016

    • Search Google Scholar
    • Export Citation
View More View Less
  • 1 CHU de Caen, Caen, France;
  • 2 Université Caen Normandie, Medical School, Caen, France;
  • 3 Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, GIP Cyceron, Caen, France; and
  • 4 INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen, France

Response

We thank Drs. Graffeo and Lawton for their very positive comment dealing with our article. We fully agree with our colleagues’ point of view: MCA aneurysms have to be preferentially treated with microsurgical clipping. This statement is not the fancy of “open” neurosurgery but is based on very robust data.1,3 The revolution provoked by the publication of the International Subarachnoid Aneurysm Trial (ISAT) in 2005 has also had some side effects, especially in Europe. As reported by our Phoenix colleagues, the results of ISAT have been overinterpreted, and since then in many centers, only endovascular treatments are available.2 In view of our results and those of the BRAT, this situation is not consistent and may not improve in the future: Microsurgical clipping is an excellent treatment of MCA aneurysms but only if performed by trained surgeons. It therefore seems necessary that neurosurgeons, particularly in Europe, reinvest in the practice of microsurgical clipping.

This is somewhat outside the realm of evidence-based medicine, but it is interesting to note that the “clip-first policy” center (University Hospital of Caen) was a “coil-first policy” center before 2010, as it is often the case in France. It is by noting that most of the complications of endovascular treatments have occurred in patients with MCA aneurysms that we decided to return to microsurgical treatment. We then observed good results, which led to a complete shift to a “clip-first policy.” Of course, the resumption of a vascular microsurgery activity does not happen overnight, but it does not require exceptional skills either. It is important to note that most of the surgeries reported in our article were done by the senior author (T.G.) but who was at that time a young neurosurgeon starting his subspecialization in vascular neurosurgery and that our hospital was not equipped with a microscope incorporating infracyanine green (ICG) angiography. With training, but also with the contribution of ICG angiography, the results of our MCA aneurysm clipping improved again, and if we had continued the study after 2016, it is possible that the benefit of microsurgery on endovascular treatment could have been even more significant.

Like Drs. Graffeo and Lawton, we encourage our neurosurgeon colleagues to reinvest in the management of MCA aneurysms. Each patient with this type of aneurysm, regardless of the center in which he or she is being treated, must be able to benefit from microsurgical clipping by a trained vascular neurosurgeon or at least this therapeutic option should be discussed.

References

  • 1

    Alreshidi M, Cote DJ, Dasenbrock HH, Acosta M, Can A, Doucette J, : Coiling versus microsurgical clipping in the treatment of unruptured middle cerebral artery aneurysms: a meta-analysis. Neurosurgery 83:879889, 2018

    • Search Google Scholar
    • Export Citation
  • 2

    Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, : International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:809817, 2005

    • Search Google Scholar
    • Export Citation
  • 3

    Mooney MA, Simon ED, Brigeman S, Nakaji P, Zabramski JM, Lawton MT, : Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial. J Neurosurg 130:895901, 2018

    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Contributor Notes

Correspondence Christopher S. Graffeo: graffeo.christopher@mayo.edu.

INCLUDE WHEN CITING Published online December 20, 2019; DOI: 10.3171/2019.10.JNS192859.

Disclosures The authors report no conflict of interest.

  • 1

    Berro DH, L’Allinec V, Pasco-Papon A, Emery E, Berro M, Barbier C, : Clip-first policy versus coil-first policy for the exclusion of middle cerebral artery aneurysms. J Neurosurg [epub ahead of print September 20, 2019. DOI: 10.3171/2019.5.JNS19373]

    • Search Google Scholar
    • Export Citation
  • 2

    Lindgren A, Vergouwen MDI, van der Schaaf I, Algra A, Wermer M, Clarke MJ, : Endovascular coiling versus neurosurgical clipping for people with aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 8:CD003085, 2018

    • Search Google Scholar
    • Export Citation
  • 3

    Mooney MA, Simon ED, Brigeman S, Nakaji P, Zabramski JM, Lawton MT, : Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial. J Neurosurg 130:895901, 2018

    • Search Google Scholar
    • Export Citation
  • 4

    Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Nakaji P, : Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg [epub ahead of print March 8, 2019. DOI: 10.3171/2018.8.JNS181846]

    • Search Google Scholar
    • Export Citation
  • 5

    Spetzler RF, Zabramski JM, McDougall CG, Albuquerque FC, Hills NK, Wallace RC, : Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg 128:120125, 2018

    • Search Google Scholar
    • Export Citation
  • 6

    Steklacova A, Bradac O, Charvat F, De Lacy P, Benes V: “Clip first” policy in management of intracranial MCA aneurysms: single-centre experience with a systematic review of literature. Acta Neurochir 158:533546, 2016

    • Search Google Scholar
    • Export Citation
  • 7

    Zijlstra IA, Verbaan D, Majoie CB, Vandertop P, van den Berg R: Coiling and clipping of middle cerebral artery aneurysms: a systematic review on clinical and imaging outcome. J Neurointerv Surg 8:2429, 2016

    • Search Google Scholar
    • Export Citation
  • 1

    Alreshidi M, Cote DJ, Dasenbrock HH, Acosta M, Can A, Doucette J, : Coiling versus microsurgical clipping in the treatment of unruptured middle cerebral artery aneurysms: a meta-analysis. Neurosurgery 83:879889, 2018

    • Search Google Scholar
    • Export Citation
  • 2

    Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, : International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:809817, 2005

    • Search Google Scholar
    • Export Citation
  • 3

    Mooney MA, Simon ED, Brigeman S, Nakaji P, Zabramski JM, Lawton MT, : Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial. J Neurosurg 130:895901, 2018

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 89 89 0
Full Text Views 116 116 70
PDF Downloads 51 51 19
EPUB Downloads 0 0 0