Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
Neurosurg Rev. 2024 Oct 26;47(1):824. doi: 10.1007/s10143-024-03057-w.
The choice between clipping and coiling of ruptured cerebral aneurysms in subarachnoid hemorrhage (SAH) remains controversial. The recently published Earlydrain trial provides the opportunity to analyze the latest clip-to-coil ratio in German-speaking countries and to evaluate vasospasm incidence and explorative outcome measures in both treatment modalities. We performed a post hoc analysis of the Earlydrain trial, a multicenter randomized controlled trial investigating the use of an additional lumbar drain in aneurysmal SAH. The decision whether to clip or to coil the ruptured aneurysm was left to the discretion of the participating centers, providing a real-world insight into current aneurysm treatment strategies. Earlydrain was performed in 19 centers in Germany, Switzerland, and Canada, recruiting 287 patients with aneurysmal SAH of all severity grades. Of these, 140 patients (49%) received clipping and 147 patients (51%) coiling. Age and clinical severity based on Hunt-Hess/WFNS grades and radiological criteria were similar. Clipping was more frequently used for anterior circulation aneurysms (55%), whereas posterior circulation aneurysms were mostly coiled (86%, p < 0.001). In high-volume recruiting centers, 56% of patients were treated with clipping, compared to 38% in other centers. A per-year analysis showed a stable and balanced clipping/coiling ratio over time. Regarding vasospasm, 60% of clipped versus 43% of coiled patients showed elevated transcranial Doppler criteria (p = 0.007), reflected in angiographic vasospasm rates (51% vs. 38%, p = 0.03). In contrast to the Earlydrain main results establishing the superiority of an additional lumbar drain, explorative outcomes after clipping and coiling measured by secondary infarctions, mortality, modified Rankin Score, Glasgow Outcome Scale Extended, or Barthel-Index showed no significant differences after discharge and at six months. In clinical practice, aneurysm clipping is still a frequently used method in aneurysmal SAH. Apart from a higher rate of vasospasm in the clipping group, an exploratory outcome analysis showed no difference between the two treatment methods. Further development of periprocedural treatment modalities for clipped ruptured aneurysms to reduce vasospasm is warranted.
在蛛网膜下腔出血（SAH）中，夹闭和线圈栓塞破裂的脑动脉瘤的选择仍然存在争议。最近发表的 Earlydrain 试验提供了分析德语国家最新夹闭-线圈比的机会，并评估了两种治疗方法的血管痉挛发生率和探索性结果测量。我们对 Earlydrain 试验进行了事后分析，该试验是一项多中心随机对照试验，研究了在动脉瘤性 SAH 中使用额外的腰椎引流。决定是否夹闭或线圈栓塞破裂的动脉瘤由参与中心自行决定，为当前的动脉瘤治疗策略提供了真实的见解。Earlydrain 在德国、瑞士和加拿大的 19 个中心进行，招募了所有严重程度级别的动脉瘤性 SAH 患者 287 例。其中，140 例（49%）接受夹闭，147 例（51%）接受线圈栓塞。年龄和临床严重程度基于 Hunt-Hess/WFNS 分级和影像学标准相似。夹闭更常用于前循环动脉瘤（55%），而后循环动脉瘤主要采用线圈栓塞（86%，p<0.001）。在高容量招募中心，56%的患者接受夹闭治疗，而其他中心为 38%。每年的分析显示，随着时间的推移，夹闭/线圈栓塞的比例保持稳定和平衡。关于血管痉挛，夹闭组有 60%的患者出现经颅多普勒标准升高，而线圈栓塞组为 43%（p=0.007），反映在血管造影血管痉挛率上（51%比 38%，p=0.03）。与 Earlydrain 的主要结果（证明额外腰椎引流的优越性）相反，通过二次梗死、死亡率、改良 Rankin 评分、格拉斯哥结局量表扩展或巴氏指数测量的夹闭和线圈栓塞后的探索性结果在出院后和 6 个月时没有显示出显著差异。在临床实践中，动脉瘤夹闭在动脉瘤性 SAH 中仍然是一种常用的方法。除了夹闭组血管痉挛发生率较高外，两种治疗方法之间的探索性结果分析没有差异。进一步开发夹闭破裂动脉瘤的围手术期治疗方法以减少血管痉挛是必要的。
