• Antti Lindgren, Ellie Bragan Turner, Tomas Sillekens, Atte Meretoja, Jin-Moo Lee, Thomas M Hemmen, Timo Koivisto, Mark Alberts, Robin Lemmens, Juha E Jääskeläinen, VergouwenMervyn D IMDIDepartment of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands., RinkelGabriel J EGJEDepartment of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands., Stroke GOAL Group, Dr Foster Global Comparators Project, Dr Foster Ltd, and Dr Foster Unit at Imperial College London.
• Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
• Neurosurgery. 2019 May 1; 84 (5): 1019-1027.

BackgroundWithin randomized clinical trials (RCTs), coiling of the ruptured aneurysm to prevent rebleeding results in better outcomes than clipping in patients with aneurysmal subarachnoid hemorrhage (aSAH).ObjectiveTo study the association of coiling and clipping with outcome after aSAH in daily clinical practice.MethodsIn this controlled, nonrandomized study, we compared outcomes after endovascular coiling and neurosurgical clipping of ruptured intracranial aneurysms in an administrative dataset of 7658 aSAH patients (22 tertiary care hospitals from Europe, USA, Australia; 2007-2013). Because the results contradicted those of the randomized trials, findings were further explored in a large clinical dataset from 2 European centers (2006-2016) of 1501 patients.ResultsIn the administrative dataset, the crude 14-d case-fatality rate was 6.4% (95% confidence interval [CI] 5.6%-7.2%) after clipping and 8.2% (95% CI 7.4%-9.1%) after coiling. After adjustment for age, sex, and comorbidity/severity, the odds ratio (OR) for 14-d case-fatality after coiling compared to clipping was 1.32 (95% CI 1.10-1.58). In the clinical dataset crude 14-d case fatality rate was 5.7% (95% CI 4.2%-7.8%) for clipping and 9.0% (95% CI 7.3%-11.2%) for coiling. In multivariable logistic regression analysis, the OR for 14-d case-fatality after coiling compared to clipping was 1.7 (95% CI 1.1-2.7), for 90-d case-fatality 1.28 (95% CI 0.91-1.82) and for 90-d poor functional outcome 0.78 (95% CI 0.6-1.01).ConclusionIn clinical practice, coiling after aSAH is associated with higher 14-d case-fatality than clipping and nonsuperior outcomes at 90 d. Both options need to be considered in aSAH patients. Further studies should address the reasons for the discrepancy between current data and those from the RCTs.Copyright © 2018 by the Congress of Neurological Surgeons.

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