大脑中动脉动脉瘤的手术或血管内治疗：一项随机比较。
Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison.
机构信息
Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada.
Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
出版信息
World Neurosurg. 2021 May;149:e521-e534. doi: 10.1016/j.wneu.2021.01.142. Epub 2021 Feb 5.
OBJECTIVE
There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials.
METHODS
Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded.
RESULTS
There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02-0.19) for clipping and 13/48 (27%; 95% CI, 0.17-0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09-0.33) cases, and 8/33 (24%; 95% CI, 0.13-0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60-0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22-0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54-0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36-0.70) patients with RA allocated coiling.
CONCLUSIONS
Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.
目的
比较大脑中动脉（MCA）动脉瘤夹闭术和血管内介入治疗的随机数据较少。我们分析了参加 CURES（协作性未破裂颅内血管与手术）和 ISAT-2（国际蛛网膜下腔动脉瘤试验 II）随机试验的 MCA 动脉瘤患者的结果。
方法
这两项试验均为研究者主导的平行分组 1:1 随机研究。CURES 纳入了 3-25mm 未破裂颅内动脉瘤（UIA）患者，ISAT-2 纳入了破裂动脉瘤（RA）患者，这些患者在 ISAT 后仍存在不确定性。CURES 的主要结局指标是治疗失败：1）未能治疗动脉瘤，2）随访期间颅内出血，或 3）1 年后仍存在残余动脉瘤。ISAT-2 的主要结局是 1 年时死亡或残疾（改良 Rankin 量表评分>2）。系统记录了 1 年的血管造影结果。
结果
共纳入 100 例未破裂和 71 例破裂 MCA 动脉瘤。在 CURES 中，90 例 UIA 患者已接受治疗，10 例患者等待治疗。夹闭和血管内介入治疗未破裂 MCA 动脉瘤的治疗失败率分别为 3/42（7%；95%置信区间 [CI]，0.02-0.19）和 13/48（27%；95% CI，0.17-0.41）（P=0.025）。所有 71 例 RA 患者均已接受治疗。在 ISAT-2 中，手术治疗的破裂 MCA 动脉瘤患者死亡或残疾（改良 Rankin 量表评分>2）的比例分别为 7/38（18%；95% CI，0.09-0.33）和 8/33（24%；95% CI，0.13-0.41）。80 例 UIA 患者和 62 例 RA 患者有 1 年影像学结果。夹闭治疗的 40 例 UIA 患者中，30 例（75%；95% CI，0.60-0.86）完全闭塞动脉瘤，40 例 UIA 患者中有 14 例（35%；95% CI，0.22-0.50）接受血管内治疗。夹闭治疗的 34 例 RA 患者中，24 例（71%；95% CI，0.54-0.83）完全闭塞动脉瘤，28 例 RA 患者中有 15 例（54%；95% CI，0.36-0.70）接受血管内治疗。
结论
两项试验的随机数据表明，MCA 动脉瘤患者的手术治疗可能获得更好的疗效。
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