Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial

Robert F. Spetzler, Joseph M. Zabramski, Cameron G. McDougall, Felipe C. Albuquerque, Nancy K. Hills, Robert C. Wallace, Peter Nakaji

Research output: Contribution to journalArticle

Abstract

OBJECTIVE The Barrow Ruptured Aneurysm Trial (BRAT) is a prospective, randomized trial in which treatment with clipping was compared to treatment with coil embolization. Patients were randomized to treatment on presentation with any nontraumatic subarachnoid hemorrhage (SAH). Because all other randomized trials comparing these 2 types of treatments have been limited to saccular aneurysms, the authors analyzed the current BRAT data for this subgroup of lesions. METHODS The primary BRAT analysis included all sources of SAH: nonaneurysmal lesions∗saccular, blister, fusiform, and dissecting aneurysms∗and SAHs from an aneurysm associated with either an arteriovenous malformation or a fstula. In this post hoc review, the outcomes for the subgroup of patients with saccular aneurysms were further analyzed by type of treatment. The extent of aneurysm obliteration was adjudicated by an independent neuroradiologist not involved in treatment. RESULTS Of the 471 patients enrolled in the BRAT, 362 (77%) had an SAH from a saccular aneurysm. Patients with saccular aneurysms were assigned equally to the clipping and the coiling cohorts (181 each). In each cohort, 3 patients died before treatment and 178 were treated. Of the 178 clip-assigned patients with saccular aneurysms, 1 (1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. There was no statistically signifcant difference in poor outcome (modifed Rankin Scale score >∗2) between these 2 treatment arms at any recorded time point during 6 years of follow-up. After the initial hospitalization, 1 of 241 (0.4%) clipped saccular aneurysms and 21 of 115 (18%) coiled saccular aneurysms required retreatment (p <∗0.001). At the 6-year follow-up, 95% (95/100) of the clipped aneurysms were completely obliterated, compared with 40% (16/40) of the coiled aneurysms (p <∗0.001). There was no difference in morbidity between the 2 treatment groups (p = 0.10). CONCLUSIONS In the subgroup of patients with saccular aneurysms enrolled in the BRAT, there was no signifcant difference between modifed Rankin Scale outcomes at any follow-up time in patients with saccular aneurysms assigned to clipping compared with those assigned to coiling (intent-to-treat analysis). At the 6-year follow-up evaluation, rates of retreatment and complete aneurysm obliteration signifcantly favored patients who underwent clipping compared with those who underwent coiling.

Original languageEnglish (US)
Pages (from-to)120-125
Number of pages6
JournalJournal of neurosurgery
Volume128
Issue number1
DOIs
StatePublished - Jan 2018
Externally publishedYes

Keywords

  • BRAT
  • Clip occlusion
  • Coil embolization
  • ISAT
  • Intracranial aneurysm
  • Randomized trial
  • SAH
  • Saccular aneurysms
  • Subarachnoid hemorrhage
  • Vascular disorders

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

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  • Cite this

    Spetzler, R. F., Zabramski, J. M., McDougall, C. G., Albuquerque, F. C., Hills, N. K., Wallace, R. C., & Nakaji, P. (2018). Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. Journal of neurosurgery, 128(1), 120-125. https://doi.org/10.3171/2016.9.JNS161301