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Comparative Study
. 2017 Aug;88(8):663-668.
doi: 10.1136/jnnp-2016-315433. Epub 2017 Jun 20.

Surgical clipping or endovascular coiling for unruptured intracranial aneurysms: a pragmatic randomised trial

Tim E Darsaut  1 , J Max Findlay  1 , Elsa Magro  2 , Marc Kotowski  3 , Daniel Roy  3 , Alain Weill  3 , Michel W Bojanowski  4 , Chiraz Chaalala  4 , Daniela Iancu  5 , Howard Lesiuk  6 , John Sinclair  6 , Felix Scholtes  7 , Didier Martin  7 , Michael M Chow  1 , Cian J O'Kelly  1 , John H Wong  8 , Ken Butcher  9 , Allan J Fox  10 , Adam S Arthur  11 , Francois Guilbert  3 , Lu Tian  12 , Miguel Chagnon  13 , Suzanne Nolet  14 , Guylaine Gevry  14 , Jean Raymond  3
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Free article
Comparative Study

Surgical clipping or endovascular coiling for unruptured intracranial aneurysms: a pragmatic randomised trial

Tim E Darsaut et al. J Neurol Neurosurg Psychiatry. 2017 Aug.
Free article

Abstract

Background: Unruptured intracranial aneurysms (UIAs) are increasingly diagnosed and are commonly treated using endovascular treatment or microsurgical clipping. The safety and efficacy of treatments have not been compared in a randomised trial. How to treat patients with UIAs suitable for both options remains unknown.

Methods: We randomly allocated clipping or coiling to patients with one or more 3-25 mm UIAs judged treatable both ways. The primary outcome was treatment failure, defined as: initial failure of aneurysm treatment, intracranial haemorrhage or residual aneurysm on 1-year imaging. Secondary outcomes included neurological deficits following treatment, hospitalisation >5 days, overall morbidity and mortality and angiographic results at 1 year.

Results: The trial was designed to include 260 patients. An analysis was performed for slow accrual: 136 patients were enrolled from 2010 through 2016 and 134 patients were treated. The 1-year primary outcome, available for 104 patients, was reached in 5/48 (10.4% (4.5%-22.2%)) patients allocated surgical clipping, and 10/56 (17.9% (10.0%-29.8%)) patients allocated endovascular coiling (OR: 0.54 (0.13-1.90), p=0.40). Morbidity and mortality (modified Rankin Scale>2) at 1 year occurred in 2/48 (4.2% (1.2%-14.0%)) and 2/56 (3.6% (1.0%-12.1%)) patients allocated clipping and coiling, respectively. New neurological deficits (15/65 vs 6/69; OR: 3.12 (1.05-10.57), p=0.031), and hospitalisations beyond 5 days (30/65 vs 6/69; OR: 8.85 (3.22-28.59), p=0.0001) were more frequent after clipping.

Conclusion: Surgical clipping or endovascular coiling of UIAs did not show differences in morbidity at 1 year. Trial continuation and additional randomised evidence will be necessary to establish the supposed superior efficacy of clipping.

Keywords: endovascular coiling; pragmatic trial; randomized controlled trial; surgical clipping; unruptured intracranial aneurysm.

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Conflict of interest statement

Competing interests: None declared.