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Randomized Controlled Trial
. 2021 May:149:e521-e534.
doi: 10.1016/j.wneu.2021.01.142. Epub 2021 Feb 5.

Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison

Tim E Darsaut  1 , Michael B Keough  1 , Abdelaziz Sagga  1 , Vivien K Y Chan  1 , Ange Diouf  2 , William Boisseau  2 , Elsa Magro  3 , Marc Kotowski  2 , Daniel Roy  2 , Alain Weill  2 , Daniela Iancu  2 , Michel W Bojanowski  4 , Chiraz Chaalala  4 , Alain Bilocq  5 , Laurent Estrade  6 , Jean-Paul Lejeune  7 , Nicolas Bricout  6 , Felix Scholtes  8 , Didier Martin  8 , Bernard Otto  9 , J Max Findlay  1 , Michael M Chow  1 , Cian J O'Kelly  1 , Robert A Ashforth  10 , Jeremy L Rempel  10 , Howard Lesiuk  11 , John Sinclair  11 , David J Altschul  12 , Fuat Arikan  13 , Francois Guilbert  2 , Miguel Chagnon  14 , Behzad Farzin  15 , Guylaine Gevry  15 , Jean Raymond  16
Affiliations
Randomized Controlled Trial

Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison

Tim E Darsaut et al. World Neurosurg. 2021 May.

Abstract

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.

Keywords: Care trial; Endovascular coiling; Intracranial aneurysm; MCA aneurysm; Randomized trial; Surgical clipping.

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