Original Research The Role of Endovascular Treatment for Ruptured Distal Anterior Cerebral Artery Aneurysms: Comparison with Microsurgical Clipping Keun Young Park, MD, Byung Moon Kim, MD, PhD, Yong Cheol Lim, MD, Joonho Chung, MD, PhD, Dong Joon Kim, MD, PhD, Jin Yang Joo, MD, PhD, Seung Kon Huh, MD, PhD, Dong Ik Kim, MD, PhD, Kyu Chang Lee, MD, PhD, Jae Whan Lee, MD From the Department of Neurosurgery (KYP, JC, JYJ, SKH, KCL, JWL) Department of Radiology (KYP, BMK, DJK, DIK), Yonsei University College of Medicine, Seoul, Republic of Korea; and Department of Neurosurgery, Ajou University School of Medicine, Suwon-si, Gyeonggi-do, Republic of Korea (YCL).
ABSTRACT BACKGROUND AND PURPOSE
The purpose of this study was to compare clinical outcomes and treatment-related complications between coiling and clipping for ruptured distal anterior cerebral artery (DACA) aneurysms. METHODS
Eighty-four consecutive patients (M:F = 36:48; mean 53.8 years) with ruptured DACA aneurysms were treated by either clipping (n = 46, 54.8%) or coiling (n = 38, 45.2%). The clinical outcomes and procedure-related complications were evaluated and compared between the two groups. RESULTS
Procedure-related complications tend to occur more frequently in the clipping (n = 6, 13.0%) than coiling group (n = 1, 2.6%) (P = .121). At discharge, 51 patients (60.7%) had favorable outcomes (Glasgow outcome scale [GOS], 4 or 5). There was no significant difference between the two groups in favorable outcome (63.2% vs. 58.7%; P = .677). Hunt and Hess (HH) grade (P < .001; 95% CI, 3.354-29.609) and treatment modality (P = .044; 95% CI, 1.039-16.325) were independent risk factors for poor outcome (GOS, 1-3). CONCLUSIONS
Coiling was more favorable to clipping in clinical outcomes and incidence of treatmentrelated complications for ruptured DACA aneurysms.
Introduction Distal anterior cerebral artery (DACA) aneurysms—also known as pericallosal aneurysms—are an infrequent cause of subarachnoid hemorrhage.1 Although there are some reports in the literature of successful treatment of DACA aneurysms by the standard interhemispheric approach,2–6 surgical clipping of these lesions has been considered a technically challenging procedure due to the risk of vein injury, narrow surgical field, dense adherence of cingulate gyri, difficult proximal control, and the high risk of intraprocedural rupture.2, 7, 8 Furthermore, intracerebral hemorrhage occurs more frequently in ruptured DACA aneurysms than in other types of aneurysms,9, 10 which has the potential to make surgery more difficult and affect poor clinical outcome.11 Endovascular coiling has been established as an alternative treatment to surgical clipping for ruptured intracranial aneurysms,1, 12 and coiling for DACA aneurysms has been
Copyright
Keywords: Intracranial aneurysm, ruptured, distal anterior cerebral artery, treatment, complications, outcome. Acceptance: Received May 6, 2013, and in revised form September 26, 2013. Accepted for publication October 14, 2013. Correspondence: Address correspondence to Jae Whan Lee, MD, Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul 120-752, Republic of Korea. E-mail: leejw@yuhs. ac. Disclosure: No funds were received in support of this work. Conflicts of Interest: None J Neuroimaging 2015;25:81-86. DOI: 10.1111/jon.12073
evaluated previously.13–16 Initial attempts at coiling for DACA aneurysms have been unsuccessful, with failures attributed to the small size and relative wide neck of the aneurysms and the anatomical constraints.15 However, with the development of newer neurointerventional techniques and devices, favorable results have subsequently been reported.13, 14, 16 The purpose of this study was to compare clinical outcomes and treatment-related complications between coiling and clipping for ruptured DACA aneurysms.
Methods We recruited 84 patients with ruptured DACA aneurysms, representing 2.6% of the overall pool of the 3,231 patients with ruptured intracranial aneurysms. Patients with dissecting, infectious, and traumatic aneurysms were excluded from this study. These DACA aneurysms were treated with either
◦ 2013 by the American Society of Neuroimaging C
81
surgical clipping (n = 46, 54.8%) or endovascular coiling (n = 38, 45.2%) between November 1997 and March 2012. Baseline characteristics and clinical data of patients were collected from medical records and an aneurysm database. Radiologic studies were also obtained and evaluated. These data were retrospectively reviewed and the clipping and coiling groups were compared by one neuroradiologist and one neurosurgeon. Informed consent was obtained from the patient or legal representatives.
Imaging Assessment In all cases, a preprocedural CT scan was performed at the time of admission and was evaluated for Fisher grading. The characteristics of the aneurysm were also evaluated by digital subtraction angiography (DSA). A postprocedural CT scan was performed on all patients within 24 hours of the procedure. A follow-up imaging study was performed at 6 months or more after coiling by DSA or magnetic resonance angiography (MRA). A follow-up angiography was not routinely performed in the clipping group.
Clinical Assessment All patients were clinically assessed at the time of admission using the Hunt & Hess (HH) grading system. Based on the initial HH grade, the patients were divided into two groups (group 1: HH grade 1 to 3; group 2: HH grade 4 or 5) for subgroup analysis. Vascular risk factors were also evaluated and recorded by history taking, physical examination, and laboratory investigation at initial admission. Procedure-related complications were defined as any neurologic morbidity/mortality that could affect patient’s clinical status after treatment. These were evaluated by the immediate postprocedural imaging studies, medical records, and an aneurysm database. Clinical outcome was assessed at the time of discharge using the Glasgow outcome scale (GOS); unfavorable outcomes were defined as GOS 1 to 3.
Determination of Treatment Modality The selection of treatment modality was not randomized. The clinical status, aneurysm characteristics, and related angioarchitectures of the patients were evaluated and discussed before the procedure. Based on these data, experienced neurosurgeons and neuroradiologists discussed and selected a treatment modality by consensus. In general, endovascular treatment was more preferable in (1) aneurysm with dome to neck ratio > 1.5 and (2) patients of poor or complicated clinical status, while surgical treatment was more preferable in (1) aneurysm with branch artery incorporation and (2) patients with large-volume hematoma that present a symptom and sign requiring urgent operation. However, this policy was not mandatory and coiling for aneurysm with wide neck or branch incorporation could be feasible along with the development of neurointervention techniques and devices during the period.17
Surgical Procedure Surgical clipping was performed by the standard technique. The most common route for DACA aneurysm repair is the interhemispheric approach (n = 40, 87.0%), while the pteri-
82
onal approach is sometimes used for aneurysms at the origin of the orbitofrontal artery (n = 6, 13.0%). All procedures were performed under somatosensory-evoked potential (SSEP) and transcranial Doppler (TCD) monitoring. Motor-evoked potential (MEP) could be monitored only in four cases (8.7%), as MEP monitoring systems were equipped only after 2008.
Endovascular Procedure All procedures were performed under endotracheal general anesthesia, with the exception of a single case in which acute rebleeding occurred during diagnostic angiography, and thus urgent coil embolization was performed under intravenous sedation. Systemic heparinization was withheld or delayed until successful deployment of first or more coils due to concerning rebleeding. If stent-assist coiling was expected, then a loading dose of dual antiplatelet agents (aspirin 300 mg and clopidogrel 300 mg) was prescribed to the patient before the procedure. Single-microcatheter coiling was performed in 32 cases (84.2%). Balloon-assist technique was used in four cases for the purpose of prevention of coil protrusion (n = 2), thrombolysis (n = 1), and premature rupture (n = 1), while the double-microcatheter technique and the stent-assist technique were only used in one case each due to anatomical constraints (ie, a wide vessel neck or incorporation of the branch artery). Accompanying with coiling, urgent surgical procedures (ie, hematoma removal or cerebrospinal fluid drainage) were required in some cases (n = 11, 28.9%).
Statistical Analysis Univariate analysis to compare the baseline characteristics of the two groups was done using the Chi-squared test, Fisher’s exact test, and standard t-tests. For the evaluation of factors predicting clinical outcomes, all variables were analyzed by univariate analysis. The variables with P-value < .1 or clinical importance were included in the multivariate analysis using a binary logistic regression model (backward conditional method). Significance was defined as a P-value < .05. These statistical analyses were performed using IBM SPSS Statistics 20.0 for Windows (IBM Corp., NY, USA).
Results The baseline characteristics of the patients are summarized and compared in Table 1. No significant difference in the baseline characteristics and radiologic findings was observed between the clipping and coiling groups except in HH grade. Overall, there were 36 male and 48 female patients, with a mean age of 53.8 years (range: 28-76). The HH grade distribution was significantly different between the two groups with a mean HH grade 2.9 ± 0.79 in clipping and 3.3 ± 1.09 in coiling, respectively (P = .040). The initial HH grade was between 1 and 3 in 64 cases (76.2%) and was either 4 or 5 in 20 cases (23.8%). Initial CT scans revealed that patient’s distribution by Fisher grade was not different between the two groups (P = .552). The average maximal aneurysm diameter was 5.68 ± 2.080 mm (5.40 ± 1.982 mm in clipping vs. 6.01 ± 2.172 mm in coiling, P = .179). The average neck size was 2.94 ± 0.857 mm
Journal of Neuroimaging Vol 25 No 1 January/February 2015
Table 1. Baseline Characteristics and Comparison between the Clipping and Coiling Groups
Overall
Clipping Group (n = 46) [1997-2012]
Coiling Group (n = 38) [2000-2012]
P Value
36 (42.9%):48 (57.1%) 53.8 ± 10.88 (28∼76)
18 (39.1%):28 (60.9%) 54.1 ± 10.93
18 (47.4%):20 (52.6%) 53.4 ± 10.95
.448 .774
32 (38.1%) 5 (6.0%) 14 (16.7%) 3 (3.6%) 3 (3.6%) 3.1 ± 0.96 64 (76.2%) 20 (23.8%)
21 (45.7%) 3 (6.5%) 5 (10.9%) 2 (4.3%) 1 (2.2%) 2.9 ± 0.79 39 (84.8%) 7 (15.2%)
11 (28.9%) 2 (5.3%) 9 (23.7%) 1 (2.6%) 2 (5.3%) 3.3 ± 1.09 25 (65.8%) 13 (34.2%)
.117 1.0 .117 1.0 .587 .040
3.2 ± 0.81 5.68 ± 2.080 2.94 ± 0.857
3.1 ± 0.83 5.40 ± 1.982 2.93 ± 0.842
3.2 ± 0.79 6.01 ± 2.172 2.96 ± 0.879
.552 .179 .911
Factors
Clinical Sex Male:Female Age (mean) Vascular risk factors Hypertension Diabetes Smoking history Heart disease Old CVA history Hunt-Hess grade (mean) 1 to 3 4 or 5 Radiologic Fisher grade (mean) Aneurysm size Aneurysm neck size CVA = Cerebrovascular accident.
Table 2. Procedural Outcomes Overall, n (%) Outcomes
Technical success rate Procedure-related Morbidity Mortality Overall
Clip
Coil
P Value
46 (100)
38 (100)
NS
1 (2.6) 0 1 (2.6)
.121
5 (10.9) 1 (2.2) 6 (13.0)
NS = not statistical.
(2.93 ± 0.842 mm in clipping vs. 2.96 ± 0.879 mm in coiling, P = .911).
Procedural Outcome Procedural outcomes are summarized in Table 2. There was no technical failure in both clipping and coiling groups. Procedurerelated complications tended to occur more frequently in the clipping group, although this was not a statistically significant difference (n = 6 [13.0%] with clips vs. n = 1 [2.6%] with coils, P = .121). In terms of morbidity (10.9%), four cases of venous infarction/hemorrhage and one case of retraction injury were observed. Surgical revision due to these complications was performed in three cases, after which their functional grade worsened. The 2 patients who did not require surgical revision also suffered from cognitive and psychiatric impairment. Intraoperative rupture occurred in five cases (10.9%) and most cases were managed effectively. However, in one mortality case (2.2%), it was controlled by a lengthy temporary occlusion of left ACA (more than 30 minutes), which resulted in territorial infarction with hemorrhagic transformation. No further surgical treatment could be performed and care was withdrawn due to poor neurologic status and very poor prognosis.
Intraprocedural thrombus was detected in four cases in the coiling group (10.5%), three of which were resolved using thrombolytic therapy (n = 2 for chemical thrombolysis, n = 1 for mechanical thrombolysis) without symptomatic infarction. However, the other patient suffered from ACA territory infarction despite successful thrombolytic therapy (2.6%). No intraprocedural aneurysm perforation was noted during the coiling. No puncture site or contrast-related problems were identified in the coiling group. Among 11 patients urgently treated by surgical procedures after coiling, no symptomatic complication was noted.
Clinical Outcomes The clinical outcomes are summarized in Table 3 according to the Hunt-Hess grading system and treatment modality. The average in-hospital period was 4.7 weeks in the clipping group (range: 2-24) and 3.8 weeks in the coiling group (range: 1-8) (P = .315). No episodes of rebleeding were identified during hospitalization. At discharge, overall favorable outcomes (GOS 4 or 5) were achieved in 51 cases, and the proportion did not differ between the clipping and coiling groups (60.7%, n = 27 [58.7%] with clips vs. n = 24 [63.2%] with coils, P = .677). However, in group 1 (HH grade 1 to 3), favorable outcomes were more frequently observed after coiling than after clipping (n = 26 [66.7%] with clips vs. n = 22 [88.0%] with coils, P = .054). The clinical outcomes are also summarized in Table 4 according to the Fisher grading system and treatment modality. Favorable outcomes were more frequently achieved in lower Fisher grade group (19 [90.5%] in Fisher 1 to 2, 19 [70.4%] in Fisher 3, and 13 [36.1%] in Fisher 4, P < .001). In Fisher 4, urgent surgical procedures accompanying with coiling were successfully accomplished (n = 11, 64.7%) and favorable outcomes could not be different by treatment modality (n = 7 [36.8%] with clips vs. n = 6 [35.3%] with coils, P = .923).
Park et al: Treatment for Ruptured Distal Anterior Cerebral Artery Aneurysms
83
Table 3. Outcomes by Hunt & Hess Grade Overall, n (%) Outcomes
GOS at discharge 4 or 5 2 or 3 Death
HH Grade 1-3, n (%)
HH Grade 4 or 5, n (%)
Clip
Coil
Clip
Coil
Clip
Coil
27 (58.7) 18 (39.1) 1 (2.2)
24 (63.2) 12 (31.6) 2 (5.3)
26 (66.7) 13 (33.3) 0
22 (88.0) 3 (12.0) 0
1 (14.3) 5 (71.4) 1 (14.3)
2 (15.4) 9 (69.2) 2 (15.4)
HH grade = Hunt & Hess grade; GOS = Glasgow outcome scale.
Table 4. Outcomes by Fisher Grade Fisher Grade 1-2, n (%) Outcomes
GOS at discharge 4 or 5 2 or 3 Death
Fisher Grade 3, n (%)
Fisher Grade 4, n (%)
Clip
Coil
Clip
Coil
Clip
Coil
12 (92.3) 1 (7.7) 0
7 (87.5) 1 (12.5) 0
8 (57.1) 6 (42.9) 0
11 (84.6) 2 (15.4) 0
7 (36.8) 11 (57.9) 1 (5.3)
6 (35.3) 9 (52.9) 2 (11.8)
GOS = Glasgow outcome scale.
Table 5. Univariate Analysis for Predictors of Unfavorable Outcome at Discharge Odds Ratio
Sex Age Hypertension Diabetes Smoking history Heart disease Old CVA history HH grade Fisher grade Treatment Modality Procedure-related complications
.971 1.080 1.351 2.450 1.194 .766 3.226 8.154 4.132 1.206 4.375
95% Wald CI
.401 1.029 .550 .387 .373 .067 .281 3.079 2.009 .499 .796
2.354 1.133 3.316 15.519 3.821 8.797 37.081 21.597 8.498 2.916 24.052
P Value
.949 .002 .512 .341 .765 .830 .347
ABSTRACT BACKGROUND AND PURPOSE
The purpose of this study was to compare clinical outcomes and treatment-related complications between coiling and clipping for ruptured distal anterior cerebral artery (DACA) aneurysms. METHODS
Eighty-four consecutive patients (M:F = 36:48; mean 53.8 years) with ruptured DACA aneurysms were treated by either clipping (n = 46, 54.8%) or coiling (n = 38, 45.2%). The clinical outcomes and procedure-related complications were evaluated and compared between the two groups. RESULTS
Procedure-related complications tend to occur more frequently in the clipping (n = 6, 13.0%) than coiling group (n = 1, 2.6%) (P = .121). At discharge, 51 patients (60.7%) had favorable outcomes (Glasgow outcome scale [GOS], 4 or 5). There was no significant difference between the two groups in favorable outcome (63.2% vs. 58.7%; P = .677). Hunt and Hess (HH) grade (P < .001; 95% CI, 3.354-29.609) and treatment modality (P = .044; 95% CI, 1.039-16.325) were independent risk factors for poor outcome (GOS, 1-3). CONCLUSIONS
Coiling was more favorable to clipping in clinical outcomes and incidence of treatmentrelated complications for ruptured DACA aneurysms.
Introduction Distal anterior cerebral artery (DACA) aneurysms—also known as pericallosal aneurysms—are an infrequent cause of subarachnoid hemorrhage.1 Although there are some reports in the literature of successful treatment of DACA aneurysms by the standard interhemispheric approach,2–6 surgical clipping of these lesions has been considered a technically challenging procedure due to the risk of vein injury, narrow surgical field, dense adherence of cingulate gyri, difficult proximal control, and the high risk of intraprocedural rupture.2, 7, 8 Furthermore, intracerebral hemorrhage occurs more frequently in ruptured DACA aneurysms than in other types of aneurysms,9, 10 which has the potential to make surgery more difficult and affect poor clinical outcome.11 Endovascular coiling has been established as an alternative treatment to surgical clipping for ruptured intracranial aneurysms,1, 12 and coiling for DACA aneurysms has been
Copyright
Keywords: Intracranial aneurysm, ruptured, distal anterior cerebral artery, treatment, complications, outcome. Acceptance: Received May 6, 2013, and in revised form September 26, 2013. Accepted for publication October 14, 2013. Correspondence: Address correspondence to Jae Whan Lee, MD, Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul 120-752, Republic of Korea. E-mail: leejw@yuhs. ac. Disclosure: No funds were received in support of this work. Conflicts of Interest: None J Neuroimaging 2015;25:81-86. DOI: 10.1111/jon.12073
evaluated previously.13–16 Initial attempts at coiling for DACA aneurysms have been unsuccessful, with failures attributed to the small size and relative wide neck of the aneurysms and the anatomical constraints.15 However, with the development of newer neurointerventional techniques and devices, favorable results have subsequently been reported.13, 14, 16 The purpose of this study was to compare clinical outcomes and treatment-related complications between coiling and clipping for ruptured DACA aneurysms.
Methods We recruited 84 patients with ruptured DACA aneurysms, representing 2.6% of the overall pool of the 3,231 patients with ruptured intracranial aneurysms. Patients with dissecting, infectious, and traumatic aneurysms were excluded from this study. These DACA aneurysms were treated with either
◦ 2013 by the American Society of Neuroimaging C
81
surgical clipping (n = 46, 54.8%) or endovascular coiling (n = 38, 45.2%) between November 1997 and March 2012. Baseline characteristics and clinical data of patients were collected from medical records and an aneurysm database. Radiologic studies were also obtained and evaluated. These data were retrospectively reviewed and the clipping and coiling groups were compared by one neuroradiologist and one neurosurgeon. Informed consent was obtained from the patient or legal representatives.
Imaging Assessment In all cases, a preprocedural CT scan was performed at the time of admission and was evaluated for Fisher grading. The characteristics of the aneurysm were also evaluated by digital subtraction angiography (DSA). A postprocedural CT scan was performed on all patients within 24 hours of the procedure. A follow-up imaging study was performed at 6 months or more after coiling by DSA or magnetic resonance angiography (MRA). A follow-up angiography was not routinely performed in the clipping group.
Clinical Assessment All patients were clinically assessed at the time of admission using the Hunt & Hess (HH) grading system. Based on the initial HH grade, the patients were divided into two groups (group 1: HH grade 1 to 3; group 2: HH grade 4 or 5) for subgroup analysis. Vascular risk factors were also evaluated and recorded by history taking, physical examination, and laboratory investigation at initial admission. Procedure-related complications were defined as any neurologic morbidity/mortality that could affect patient’s clinical status after treatment. These were evaluated by the immediate postprocedural imaging studies, medical records, and an aneurysm database. Clinical outcome was assessed at the time of discharge using the Glasgow outcome scale (GOS); unfavorable outcomes were defined as GOS 1 to 3.
Determination of Treatment Modality The selection of treatment modality was not randomized. The clinical status, aneurysm characteristics, and related angioarchitectures of the patients were evaluated and discussed before the procedure. Based on these data, experienced neurosurgeons and neuroradiologists discussed and selected a treatment modality by consensus. In general, endovascular treatment was more preferable in (1) aneurysm with dome to neck ratio > 1.5 and (2) patients of poor or complicated clinical status, while surgical treatment was more preferable in (1) aneurysm with branch artery incorporation and (2) patients with large-volume hematoma that present a symptom and sign requiring urgent operation. However, this policy was not mandatory and coiling for aneurysm with wide neck or branch incorporation could be feasible along with the development of neurointervention techniques and devices during the period.17
Surgical Procedure Surgical clipping was performed by the standard technique. The most common route for DACA aneurysm repair is the interhemispheric approach (n = 40, 87.0%), while the pteri-
82
onal approach is sometimes used for aneurysms at the origin of the orbitofrontal artery (n = 6, 13.0%). All procedures were performed under somatosensory-evoked potential (SSEP) and transcranial Doppler (TCD) monitoring. Motor-evoked potential (MEP) could be monitored only in four cases (8.7%), as MEP monitoring systems were equipped only after 2008.
Endovascular Procedure All procedures were performed under endotracheal general anesthesia, with the exception of a single case in which acute rebleeding occurred during diagnostic angiography, and thus urgent coil embolization was performed under intravenous sedation. Systemic heparinization was withheld or delayed until successful deployment of first or more coils due to concerning rebleeding. If stent-assist coiling was expected, then a loading dose of dual antiplatelet agents (aspirin 300 mg and clopidogrel 300 mg) was prescribed to the patient before the procedure. Single-microcatheter coiling was performed in 32 cases (84.2%). Balloon-assist technique was used in four cases for the purpose of prevention of coil protrusion (n = 2), thrombolysis (n = 1), and premature rupture (n = 1), while the double-microcatheter technique and the stent-assist technique were only used in one case each due to anatomical constraints (ie, a wide vessel neck or incorporation of the branch artery). Accompanying with coiling, urgent surgical procedures (ie, hematoma removal or cerebrospinal fluid drainage) were required in some cases (n = 11, 28.9%).
Statistical Analysis Univariate analysis to compare the baseline characteristics of the two groups was done using the Chi-squared test, Fisher’s exact test, and standard t-tests. For the evaluation of factors predicting clinical outcomes, all variables were analyzed by univariate analysis. The variables with P-value < .1 or clinical importance were included in the multivariate analysis using a binary logistic regression model (backward conditional method). Significance was defined as a P-value < .05. These statistical analyses were performed using IBM SPSS Statistics 20.0 for Windows (IBM Corp., NY, USA).
Results The baseline characteristics of the patients are summarized and compared in Table 1. No significant difference in the baseline characteristics and radiologic findings was observed between the clipping and coiling groups except in HH grade. Overall, there were 36 male and 48 female patients, with a mean age of 53.8 years (range: 28-76). The HH grade distribution was significantly different between the two groups with a mean HH grade 2.9 ± 0.79 in clipping and 3.3 ± 1.09 in coiling, respectively (P = .040). The initial HH grade was between 1 and 3 in 64 cases (76.2%) and was either 4 or 5 in 20 cases (23.8%). Initial CT scans revealed that patient’s distribution by Fisher grade was not different between the two groups (P = .552). The average maximal aneurysm diameter was 5.68 ± 2.080 mm (5.40 ± 1.982 mm in clipping vs. 6.01 ± 2.172 mm in coiling, P = .179). The average neck size was 2.94 ± 0.857 mm
Journal of Neuroimaging Vol 25 No 1 January/February 2015
Table 1. Baseline Characteristics and Comparison between the Clipping and Coiling Groups
Overall
Clipping Group (n = 46) [1997-2012]
Coiling Group (n = 38) [2000-2012]
P Value
36 (42.9%):48 (57.1%) 53.8 ± 10.88 (28∼76)
18 (39.1%):28 (60.9%) 54.1 ± 10.93
18 (47.4%):20 (52.6%) 53.4 ± 10.95
.448 .774
32 (38.1%) 5 (6.0%) 14 (16.7%) 3 (3.6%) 3 (3.6%) 3.1 ± 0.96 64 (76.2%) 20 (23.8%)
21 (45.7%) 3 (6.5%) 5 (10.9%) 2 (4.3%) 1 (2.2%) 2.9 ± 0.79 39 (84.8%) 7 (15.2%)
11 (28.9%) 2 (5.3%) 9 (23.7%) 1 (2.6%) 2 (5.3%) 3.3 ± 1.09 25 (65.8%) 13 (34.2%)
.117 1.0 .117 1.0 .587 .040
3.2 ± 0.81 5.68 ± 2.080 2.94 ± 0.857
3.1 ± 0.83 5.40 ± 1.982 2.93 ± 0.842
3.2 ± 0.79 6.01 ± 2.172 2.96 ± 0.879
.552 .179 .911
Factors
Clinical Sex Male:Female Age (mean) Vascular risk factors Hypertension Diabetes Smoking history Heart disease Old CVA history Hunt-Hess grade (mean) 1 to 3 4 or 5 Radiologic Fisher grade (mean) Aneurysm size Aneurysm neck size CVA = Cerebrovascular accident.
Table 2. Procedural Outcomes Overall, n (%) Outcomes
Technical success rate Procedure-related Morbidity Mortality Overall
Clip
Coil
P Value
46 (100)
38 (100)
NS
1 (2.6) 0 1 (2.6)
.121
5 (10.9) 1 (2.2) 6 (13.0)
NS = not statistical.
(2.93 ± 0.842 mm in clipping vs. 2.96 ± 0.879 mm in coiling, P = .911).
Procedural Outcome Procedural outcomes are summarized in Table 2. There was no technical failure in both clipping and coiling groups. Procedurerelated complications tended to occur more frequently in the clipping group, although this was not a statistically significant difference (n = 6 [13.0%] with clips vs. n = 1 [2.6%] with coils, P = .121). In terms of morbidity (10.9%), four cases of venous infarction/hemorrhage and one case of retraction injury were observed. Surgical revision due to these complications was performed in three cases, after which their functional grade worsened. The 2 patients who did not require surgical revision also suffered from cognitive and psychiatric impairment. Intraoperative rupture occurred in five cases (10.9%) and most cases were managed effectively. However, in one mortality case (2.2%), it was controlled by a lengthy temporary occlusion of left ACA (more than 30 minutes), which resulted in territorial infarction with hemorrhagic transformation. No further surgical treatment could be performed and care was withdrawn due to poor neurologic status and very poor prognosis.
Intraprocedural thrombus was detected in four cases in the coiling group (10.5%), three of which were resolved using thrombolytic therapy (n = 2 for chemical thrombolysis, n = 1 for mechanical thrombolysis) without symptomatic infarction. However, the other patient suffered from ACA territory infarction despite successful thrombolytic therapy (2.6%). No intraprocedural aneurysm perforation was noted during the coiling. No puncture site or contrast-related problems were identified in the coiling group. Among 11 patients urgently treated by surgical procedures after coiling, no symptomatic complication was noted.
Clinical Outcomes The clinical outcomes are summarized in Table 3 according to the Hunt-Hess grading system and treatment modality. The average in-hospital period was 4.7 weeks in the clipping group (range: 2-24) and 3.8 weeks in the coiling group (range: 1-8) (P = .315). No episodes of rebleeding were identified during hospitalization. At discharge, overall favorable outcomes (GOS 4 or 5) were achieved in 51 cases, and the proportion did not differ between the clipping and coiling groups (60.7%, n = 27 [58.7%] with clips vs. n = 24 [63.2%] with coils, P = .677). However, in group 1 (HH grade 1 to 3), favorable outcomes were more frequently observed after coiling than after clipping (n = 26 [66.7%] with clips vs. n = 22 [88.0%] with coils, P = .054). The clinical outcomes are also summarized in Table 4 according to the Fisher grading system and treatment modality. Favorable outcomes were more frequently achieved in lower Fisher grade group (19 [90.5%] in Fisher 1 to 2, 19 [70.4%] in Fisher 3, and 13 [36.1%] in Fisher 4, P < .001). In Fisher 4, urgent surgical procedures accompanying with coiling were successfully accomplished (n = 11, 64.7%) and favorable outcomes could not be different by treatment modality (n = 7 [36.8%] with clips vs. n = 6 [35.3%] with coils, P = .923).
Park et al: Treatment for Ruptured Distal Anterior Cerebral Artery Aneurysms
83
Table 3. Outcomes by Hunt & Hess Grade Overall, n (%) Outcomes
GOS at discharge 4 or 5 2 or 3 Death
HH Grade 1-3, n (%)
HH Grade 4 or 5, n (%)
Clip
Coil
Clip
Coil
Clip
Coil
27 (58.7) 18 (39.1) 1 (2.2)
24 (63.2) 12 (31.6) 2 (5.3)
26 (66.7) 13 (33.3) 0
22 (88.0) 3 (12.0) 0
1 (14.3) 5 (71.4) 1 (14.3)
2 (15.4) 9 (69.2) 2 (15.4)
HH grade = Hunt & Hess grade; GOS = Glasgow outcome scale.
Table 4. Outcomes by Fisher Grade Fisher Grade 1-2, n (%) Outcomes
GOS at discharge 4 or 5 2 or 3 Death
Fisher Grade 3, n (%)
Fisher Grade 4, n (%)
Clip
Coil
Clip
Coil
Clip
Coil
12 (92.3) 1 (7.7) 0
7 (87.5) 1 (12.5) 0
8 (57.1) 6 (42.9) 0
11 (84.6) 2 (15.4) 0
7 (36.8) 11 (57.9) 1 (5.3)
6 (35.3) 9 (52.9) 2 (11.8)
GOS = Glasgow outcome scale.
Table 5. Univariate Analysis for Predictors of Unfavorable Outcome at Discharge Odds Ratio
Sex Age Hypertension Diabetes Smoking history Heart disease Old CVA history HH grade Fisher grade Treatment Modality Procedure-related complications
.971 1.080 1.351 2.450 1.194 .766 3.226 8.154 4.132 1.206 4.375
95% Wald CI
.401 1.029 .550 .387 .373 .067 .281 3.079 2.009 .499 .796
2.354 1.133 3.316 15.519 3.821 8.797 37.081 21.597 8.498 2.916 24.052
P Value
.949 .002 .512 .341 .765 .830 .347
